Integration as a scientific paradigm

Improving the quality of care in nursing home organizations with urgent quality issues: design and effectiveness of a Dutch government-funded support programme

BACKGROUND

Various societal developments are currently challenging the ability of European nursing home organizations to meet quality standards. To support nursing home organizations throughout the Netherlands in quality improvement (QI), the Dutch government launched a nationwide programme in 2016 entitled 'Dignity and pride' (D&p). As part of this programme, participating nursing home organizations followed a tailored trajectory centred around intensive, on-site support from external expert coaches. For this study, we evaluated to what extent quality improvements were realized in the programme, paying particular attention to the role of the expert coaches.

METHODS

Thirty-six nursing home organizations were included. At the start of D&p, the majority of these organizations (78%) had major quality issues as determined by the Health Care Inspectorate. Information on quality of care at the start versus end of the programme was obtained from improvement plans and final evaluation reports. Quality of person-centred care (PCC) and resident safety were quantified using a standardized assessment tool based on national guidelines, with improvements analysed using two-sided paired-sample T-tests. In addition, semi-structured interviews were conducted with 14 coaches and 29 healthcare professionals, focusing on the greatest benefits of programme participation and on the added value of the expert coaches.

RESULTS

After completion of the programme, 60% of the organizations scored a 4 (= good) on PCC and resident safety, and none scored a 2 or less (average improvement on a 5-point scale for both themes: 1.9 points, p < 0.001). Interviewees confirmed that the quality of care had both improved and become more person-centred. The expert coaches were credited with substantially contributing to the QI process by offering an outsider's perspective, bringing in experience and expertise, and helping the organization stay committed and focused.

CONCLUSIONS

Our study results suggest that the D&p programme was associated with improved quality of care in nursing home organizations with urgent quality issues. However, offering on-site tailored support through a nationally coordinated, government-funded programme is both time- and labour-intensive, and therefore not feasible in every healthcare setting. Nevertheless, the findings provide valuable insights for future QI support strategies.

An evaluation of speech and language therapy services for people with long COVID in the UK: a call for integrated care

Purpose

Long COVID is a complex and highly heterogeneous condition with a variable symptom profile, and calls have been made for an integrated care approach to be taken for its management. To date, no studies have explored speech and language therapy services or needs associated with long COVID. This service evaluation aimed to gauge the level of demand on speech and language therapy services for individuals with long COVID in the UK; their clinical needs, the organisational arrangements of services and the barriers and facilitators of delivering quality care.

Design/methodology/approach

A service evaluation was undertaken via distribution of an online survey to speech and language therapists (SLTs) receiving referrals for individuals with long COVID. Analysis was completed using descriptive statistics, with thematic analysis to evaluate qualitative data.

Findings

One hundred and eleven SLTs responded. Eighty-six percent were seeing individuals with long COVID in their “everyday” service, in uni- or multi-disciplinary teams, without any “dedicated” resource. Dysphagia and dysphonia were the most reported symptoms. Most respondents (66.7%) indicated the individuals they were seeing were of working age, and that an individuals' speech and language therapy needs were impacting their wellbeing. Perceived barriers to quality care included fragmented and non-integrated care pathways. Multi-disciplinary and integrated working was a key enabler.

Originality/value

This study provides novel insights into the current speech and language therapy needs of and care pathways for individuals with long COVID in the UK SLTs have unique expertise and are integral to supporting individuals with long COVID and should be a part of integrated care teams.

Lessons Learned from an Intersectoral Collaboration between the Public Sector, NGOs, and Sports Clubs to Meet the Needs of Vulnerable Youths

The Norwegian Government emphasizes intersectoral collaboration to achieve health goals such as reducing social health differences. However, research shows that achieving fruitful collaboration between different organizations and the public sector is challenging. The sports sector is one potential partner for such collaboration. Although the Government calls for intersectoral collaboration that includes the sports sector, there are few concrete guidelines for how this may be implemented in practice. Guided by The Bergen Model of Collaborative Functioning, the purpose of this study was to explore factors that promote or inhibit collaboration in an intersectoral project involving the sports sector, NGOs, and public sector. The current project aimed to work towards creating health promoting activities aimed at vulnerable youths. Methods: A qualitative case study of the Sports Project with interviews of eleven collaborative partners. Results: Factors promoting collaboration amongst the different partners were having a common mission, an appreciation of the partners’ complementary skills and knowledge, and a consistent user perspective. Conclusions: By orienting the collaboration towards the users’ needs, the partners have succeeded in creating tailored health-promoting activities for vulnerable youths. However, a challenge remains in transforming the collaborative project into a sustainable structure.

Patterns emerging from the TQM paradigm in relation to the 21st century complex context within TQM journal

Purpose

The purpose of this research is to explore the deployment of the total quality management (TQM) paradigm in the TQM Journal in relation to the context of the 21st century. The study builds on the theoretical framework of the four quality paradigms that together compose TQM. The four paradigms differ in their effectiveness based on the context in which they are used. In a complex context, one would expect the reflective and the emergence paradigm to flourish. The TQM Journal is one of the leading scientific journals on TQM. If the assumption that the reflective and emergent paradigm would flourish in a complex environment is correct, one will see that represented in the past five years of scientific research in that magazine.

Design/methodology/approach

The TQM Journal articles of the past five years from January 2016 till January 2021 have been chosen as the scope of an exploratory review. The author assessed the title and abstract of all articles based on the characteristics of the four quality paradigms, as described in the theoretical framework. If the title and abstract did not provide enough data to take the decision for the assessment, the whole article has been taken into account. The results have been collated, summarized and reported. Based on the results, the author explores the possible patterns.

Findings

In total, 283 articles from 2016 to 2021 (from Volume 28, Issue 1 to Volume 33, Issue 1) were included in this study. In total, 45 were read fully to be able to characterize the article. Most of the studies relate the tertiary (33.3%) and secondary (27.9%) sectors. Healthcare was the sector in 32 of the cases (11.3%). Most studies have been conducted in Europe (n = 82, 28.9%) and Asia (n = 58, 20.5%). Within Europe, Italy was the most prolific country with, respectively, 25 (30.8%) of the articles. The USA and Canada only had five articles in these five years (1.8%). Many articles did not specify the region. More than half of the articles (52.4%) worked with surveys, questionnaires or other methods to involve the customer in the research; 16 articles (5.6%) used experts in the field through expert panels and such to collect data from. In total, 107 articles (37.8%) did involve no other stakeholders than the researchers themselves. Eight studies (2.8%) used action research or co-design methodology to create optimal stakeholder participation. Based on the data, four patterns can be discovered: the context sensitivity of the articles, reflexivity, coping with uncertainty and co-creation.

Research limitations/implications

It is acknowledged that the articles in the study were published in just one scientific journal. One can expect that this will be represented in other journals on TQM. Still, it would be interesting to conduct a follow-up study in other journals on TQM and compare the results. The research is done by one subjective researcher.

Practical implications

Research on TQM should take the complexity of the context into account. For that purpose, researchers should focus more on the emergence paradigm within TQM.

Originality/value

This study is the first to investigate TQM as a holistic paradigm, including the empirical, reflective, reference and emergence paradigm in TQM research.

Research in Integrated Care: The Need for More Emergent, People-Centred Approaches

The International Foundation for Integrated Care (IFIC) recently celebrated its 20th International Conference (ICIC20) through a virtual event that brought together patients and carers, academics, care professionals, NGOs, policy-makers and industry partners from across the global integrated care community [1]. The International Journal for Integrated Care (IJIC) used this opportunity to host a workshop on published research in integrated care, specifically to reflect on the quality of existing scientific enquiry. A lively discussion on the current state of integrated care research concluded that there remained significant shortcomings to current methodologies - for example, in their ability to provide the depth of understanding required to support the knowledge needed to best inform policy and practice, particularly when addressing people-centredness. In part, the debate recognized how the nature of existing research funding, and prevailing attitudes and preferences towards certain research methodologies, were partly to blame (as has been noted by IJIC previously [23]). The workshop debated how research and researchers must change their focus in order to better contribute to the tenet of people-centred integrated care.

Reconciling practice, research and reality of integrated care. Critical reflections on the state of a discipline

Purpose

The purpose of this paper is to critically reflect on the practice, rhetoric and reality of integrating care. Echoing Le Grand's framework of motivation, agency and policy, it is argued that the stories the authors tell themselves why the authors embark on integration programmes differ from the reasons why managers commit to these programmes. This split between policy rhetoric and reality has implications for the way the authors investigate integration.

Design/methodology/approach

Examining current integration policy, practice and research, the paper adopts the critical framework articulated by Le Grand about the underlying assumptions of health care policy and practice.

Findings

It is argued that patient perspectives are speciously placed at the centre of integration policy but mask the existing organizational and managerial rationalities of integration. Making the patient the measure of all things integration would turn this agenda back on its feet.

Originality/value

The paper discusses the underlying assumptions of integration policy, practice and research. Increasing the awareness about the gap between what the authors do, why the authors do it and the stories the authors tell themselves about it injects a much needed amount of criticality into research and practice.

Case study method to design and evaluate person-centred integrated palliative and end-of-life care

Purpose

This case study aims to understand the experience of care from a patient/carer perspective and to describe how the method can be replicated to address gaps in evidence relating to integrated person-centred care.

Design/methodology/approach

The case study was constructed using data extracted from personal diaries and medical records kept by a person with a complex condition, correspondence with family from the last 18 months of life and interviews with the carer and long-term conditions coordinator. The number of professionals or teams involved in providing care from statutory services, the third sector, and private providers were counted to understand the ecosystem of care. The number of contacts was plotted by provider and purpose of care. The type of care and hours of respite were estimated. A protocol was developed to assess the feasibility of replicating the data and analyses used.

Findings

There were 35 care providers from the public, private and the third sector, demonstrating that only the patient or carer can identify the ecosystem of care. The majority of care was for respite and on average, the carer provided four hours of care per every respite care hour. The method was replicated successfully.

Research limitations/implications

The case study formed the basis of a workshop that brought together health care professionals from the public services and the third sector. The discussion led to the identification of gaps and areas where greater coordination between providers would benefit patients.

Originality/value

The case study method combines contemporaneous patient and carer sources of data and health service activity to create a detailed account of care at the end of life. The approach addresses gaps in person-centred evidence for the development and evaluation of integrated palliative and end-of-life care.

Integrated care: a definition from the perspective of the four quality paradigms

Purpose

The purpose of this paper is to support the ongoing dialogue and shed light on the different views on integrated care. An overarching definition of integrated care is proposed combining the ways of thinking of the four quality paradigms the authors identify. The idea of epistemic fluency offers a way-out of ongoing discussions about “what integration is”.

Design/methodology/approach

Four paradigms of quality are presented and applied to healthcare. Epistemic fluency is proposed as the capacity to understand, switch between and combine different kinds of knowledge. The authors compare previously developed definitions of integrated care to the various combinations of paradigms.

Findings

All four paradigms of care quality are present in healthcare and in the most used definitions of integrated care. The Reflective Paradigm and the Emergence Paradigm receive least attention. Some definitions combine more than one paradigm. An overarching definition of integrated care is proposed.

Research limitations/implications

In this paper, only the most prominent definitions of integration have been considered.

Practical implications

Integration research and practice requires a widely accepted definition of integrated care, embracing all four paradigms of care quality. Our suggestion provides a common foundation that may prevent misunderstanding.

Originality/value

The use of quality management paradigms to frame the debate on defining integrated care is new and leads to new insights for teaching, research and practice.

Sharing a vision. Do participants in integrated care programmes have the same goals and objectives?

Integrating health and social care services remains one of the most difficult undertakings in the field of care delivery. One of the key requirements for success in integration programmes is a shared vision amongst care providers. Shared visions may contain views as to what the new services should look like, how it should operate and what it should be able to achieve. The paper reports findings of an evaluation of a service integration programme in the North of England. It confirms that a programme consensus on issues such as aims and objectives and programme logics is seen by participants as a key to success. Yet, the study also found that there is a specific window of opportunity in integration programmes when participating organisations start on relatively high levels of commitment and enthusiasm which tend to tail off relatively quickly. The paper closes with a discussion about the implications of the findings for programme designers and service planners.

Big Data and what it means for evaluating integrated care programmes

Purpose

Big Data is likely to have significant implications for the way in which services are planned, organised or delivered as well as the way in which we evaluate them. The increase in data availability creates particular challenges for evaluators in the field of integrated care and the purpose of this paper is to set out how we may usefully reframe these challenges in the longer term.

Design/methodology/approach

Using the characteristics of Big Data as defined in the literature, the paper develops a narrative around the data and research design challenges and how they influence evaluation studies in the field of care integration.

Findings

Big Data will have significant implications for how we conduct integrated care evaluations. In particular, dynamic modelling and study designs capable of accommodating new epistemic foundations for the phenomena of social organisations, such as emergence and feedback loops, are likely to be most helpful. Big Data also generates opportunities for exploratory data analysis approaches, as opposed to static model development and testing. Evaluators may find research designs useful that champion realist approaches or single-n designs.

Originality/value

This paper reflects on the emerging literature and changing practice of data generation and data use in health care. It draws on organisational theory and outlines implications of Big Data for evaluating care integration initiatives.

A Realist Evaluation of Local Networks Designed to Achieve More Integrated Care

INTRODUCTION

Not surprisingly given their multi-component nature, initiatives to improve integrated care often evolve to find the best way to bring about change. This paper provides an example of how an evaluation evolved alongside such an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand.

THEORY AND METHODS

Using the explanatory power of a realist evaluative approach, theories of new ways of working that might be prompted by the initiative were explored in: (i) interviews with stakeholders in 2012 and 2015, (ii) online surveys of general practices and local care organisations, and (iii) a purposive sample of ten general practices.

RESULTS

The results highlighted the institutional contexts that led to difficulties in implementing population health initiatives. They also revealed that changes in work practices focussed mostly on activities that improved the coordination of care for individuals at risk of hospital admissions.

DISCUSSION

Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended. In the case of this intervention, the move towards strengthening local relationships arose when contractual arrangements stalled. Realist evaluative approaches offer a logic that helps unpick the complexity of the relationships and politics in play, and uncover the assumptions made by those developing, implementing and assessing health service changes.

CONCLUSION

Given the multi-component and evolving nature of initiatives seeking to better integrate care, the realist evaluative emphasis on surfacing early the theories to explain how change is expected to occur helps overcome the challenge of evaluating "a moving target".

Impact of continuity of care on quality of life in patients with chronic obstructive pulmonary disease

Purpose

Patients with chronic obstructive pulmonary disease (COPD) suffer many physical disabilities which cause many problems in their life. These patients really need to have continuity of care based on cooperation between patient, the family and their care givers in order to achieve an integration of care. The purpose of this paper is to assess the impact of continuous care on quality of life of patients with COPD.

Design/methodology/approach

A before–after quasi-experimental study was carried out with 72 patients with COPD at Beheshti educational hospital of Hamadan University of Medical Sciences. The patients who met inclusion criteria were randomly allocated into an intervention group (n=36) and a control group (n=36). The patients completed the St George’s Respiratory Questionnaire before and after their care. The intervention comprised continuous care with orientation and sensitization sessions (2 weeks), control and evaluation sessions (45 days) for intervention group and with routine care in the control group. Data were analyzed with SPSS, descriptive and inferential statistics were conducted to measure differences between intervention and control group.

Findings

Continuity of care improved significantly the quality of life of COPD patients in general, and in the symptoms, activity and impact domains (P=0.001). In contrast, routine care did not improve quality of life for patients in general, and in the symptoms, activity and impact domains (P=0.05).

Originality/value

Continuity of care has a positive impact on quality of life for COPD patients. Health care system should utilize continuity of care models as an overall plan for patients with COPD. Moreover, managers of health care system could reduce burden of chronic diseases by employing continuity of care models in planning patient care.

Care Integration - From "One Size Fits All" to Person Centred Care Comment on "Achieving Integrated Care for Older People: Shuffling the Deckchairs or Making the System Watertight for the Future?"

Integrating services is a hot topic amongst health system policy-makers and healthcare managers. There is some evidence that integrated services deliver efficiencies and reduce service utilisation rates for some patient populations. In their article on Achieving Integrated Care for Older People, Gillian Harvey and her colleagues formulate some critical insights from practice and research around integrated care. However, the real challenge is to reconcile service integration with patient experiences. This paper argues that unless we think service integration from the patient’s perspective we will continue to fail to produce the evidence we need to support integrated care solutions to the current health system challenges.

Values, interests and power: the politics of integrating services

Purpose

Differences in professional values, organisational interests and access to resources are key issues to be addressed when integrating services. They are widely seen by service planners and commissioners to be matters of governance. However, they also inform critical debates in political science. In essence they revolve around the question of distribution, or (how to decide) who gets what. The purpose of this paper is to re-frame the subject of inter-organisational governance in integration by conceptualising it through the lens of three prominent politico-theoretical approaches: the liberal, the authoritarian and the radical-utopian.

Design/methodology/approach

A discussion paper that proceeds by utilising political science terms of reference and applying it to a public management problem.

Findings

All three theories provide particular insights into the way in which service planners and commissioners may think about the inescapable plurality of values and interests in integration programmes. Where the liberal perspective places particular emphasis on the purpose and utility of organisational autonomy and self-direction, the authoritarian model highlights the need to produce results within tight timescales. It also accords with the manner in which integration policy is normally implemented, top down. The radical-utopian model is built on the least realistic assumptions but offers researchers a useful framework to assess the rationale and effectiveness of value-based policy in integration programmes wherever robust inter-organisational structures fail to materialise.

Originality/value

Whilst there has been significant research on how to conceptualise integration programmes, scholars have usually championed a public management approach. The potential insights of political thought have not been explored until now. The paper demonstrates that the wider conceptual framework of political theory has significant purchase in the field of integration studies and can help us understand the benefits and limitations of an interdisciplinary approach.