‘Complexity-compatible’ policy for integrated care? Lessons from the implementation of Ontario's Health Links

Grudniewicz, Agnes; Tenbensel, Tim; Evans, Jenna M.; Gray, Carolyn Steele; Baker, G. Ross; Wodchis, Walter P.

doi:10.1016/j.socscimed.2017.12.029

Cited by 40 publications

(59 citation statements)

References 34 publications

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“…Health Links was first introduced by the Ministry in 2012 to ensure coordinated, efficient, and effective care to patients with complex health and social care needs. The initiative started with early adopters and used a staggered approach to the implementation of new networks, resulting in 82 approved Health Links networks at the time of writing, all in different stages of implementation [37]. It targets the top 5% of health care Integration of Health Links with the Senior Care Program began with training at some sites on the coordinated care plan and the introduction of a new medical chart documentation system where the coordinated care plans would be stored and updated.…”

Section: Study Contextmentioning

confidence: 99%

Examining health care providers’ and middle-level managers’ readiness for change: a qualitative study

Austin

Chreim

Grudniewicz

2020

BMC Health Serv Res

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Background: Readiness is a critical precursor of successful change; it denotes whether those involved in the change are motivated and empowered to participate in the change. Research on readiness tends to focus on frontline providers or individuals in non-managerial positions and offers limited attention to individuals in middle management positions who are expected to lead frontline providers in change implementation. Yet middle-level managers are also recipients of changes that are planned and decreed by those in higher positions. This study sought to examine both frontline provider and middle manager readiness for change in the context of primary care program integration. Methods: Using a qualitative case study approach, we examined how frontline providers and middle managers experienced six readiness factors: discrepancy, appropriateness, valence, efficacy, fairness and trust in management. Data were collected through documents, meeting observation and semi-structured interviews with frontline providers and middle managers involved in the change. Results: The findings highlighted similarities and differences in readiness experiences of frontline providers and middle managers. Across both types of participants, we found that the notion of valence should be expanded to consider individuals' evaluation of benefits to patients and the health system; efficacy applies to both content and process of change; fairness and trust in management findings require further exploration to determine their appropriateness to be incorporated in models of readiness for change; and trust in management (or lack of trust) has a cascading influence across the levels in the organization. Conclusions: Our study makes a contribution by nuancing and extending conceptualizations of individual readiness factors, and by highlighting the central role of middle manager readiness for change. Implications of the study include the need to consider readiness factors prior to the implementation of change and the importance of fostering readiness throughout all levels of the organization.

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Section: Study Contextmentioning

confidence: 99%

Examining health care providers’ and middle-level managers’ readiness for change: a qualitative study

Austin

Chreim

Grudniewicz

2020

BMC Health Serv Res

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“…One—a mainstay of the management literature since long before CAS ideas gained currency—prescribes that leaders set clear goals (stip), then let staff decide how to achieve them (stim) . In another version, leaders encourage local innovation (stim), then use structured opportunities for shared learning and sensemaking to inform system‐level policy (stip) . Other examples of stip‐stim sequences include the “fire bullets, then cannonballs” approach to testing and scaling up innovation in a rapidly shifting context; the “master the rules, then ignore them” process that characterizes the transition from novice to expert; and the divergent and convergent phases observed in problem‐solving and organizational learning .…”

Section: Combining Stip and Stimmentioning

confidence: 99%

“…13,24 Certainly, examples abound of short-sighted, top-down schemes that produced unwanted effects in some other part of the system-or no effects at all. However, research suggests that stimulation alone tends to be inadequate to bring about largesystem change 25 ; the indiscriminate amplification of local patterns may exacerbate fragmentation and misalignment among system parts, while generating little that is of benefit to the whole. A realist review, grounded in a CAS perspective, found that large-system change demands a blend of planning and adaptation, designated and distributed leadership, direction and responsiveness-in other words, stipulation and stimulation.…”

Section: Combining Stip and Stimmentioning

confidence: 99%

The stipulation‐stimulation spiral: A model of system change

Kreindler

2019

Health Planning & Management

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Summary This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems—in particular, health care systems—respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system‐change approaches are “stipulation” and “stimulation”: stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the “stip‐stim spiral” vs “stip‐stim stalemate”) are observed to underpin successful vs failed system change: The crucial difference is whether decision‐makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system‐change efforts fail and how they can succeed.

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“…Several events converged to bring integrated care to the forefront for CCO leaders and staff. First, integrating care was increasingly a cornerstone of health reform agendas around the world . Second, the quality of cancer care delivered within the walls of RCPs was consistently improving, but provincial quality improvement efforts rarely extended beyond hospitals .…”

Section: Cancer Care Ontario's Approach To Driving Integrated Carementioning

confidence: 99%

“…Frequent hand‐offs between professionals and transitions across care settings can lead to inconsistent patient monitoring, repeated tests, delayed diagnoses, medication errors, and dissatisfied patients . International efforts to bridge these silos and improve quality of care abound, from Accountable Care Organizations in the United States and Health Links in Canada to Chains of Care in Sweden and the Pioneer Program in England . These initiatives are united by a common goal: to deliver care that is integrated across professionals and settings over time.…”

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confidence: 98%

Bridging silos: Delivering integrated care to patients with cancer in Ontario, Canada

et al. 2018

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Funding informationCanadian Partnership Against Cancer (CPAC); Cancer Care Ontario KEYWORDS cancer, integrated care, oncology, psycho-oncology, patient care, quality of lifeThe "silo" metaphor is one of the most pervasive in healthcare. A staple of the farming industry, silos are storage structures that tower over fields keeping crops such as corn and wheat separated, protected, and dry.These vertical structures standing side-by-side, but sealed from each other, are often compared to healthcare specialties, processes, units, organizations, and sectors that operate largely in isolation of one another.Silos of care are problematic for patients with complex healthcare needs such as those with cancer. Frequent hand-offs between professionals and transitions across care settings can lead to inconsistent patient monitoring, repeated tests, delayed diagnoses, medication errors, and dissatisfied patients. 1,2 International efforts to bridge these

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‘Complexity-compatible’ policy for integrated care? Lessons from the implementation of Ontario's Health Links

Cited by 40 publications

References 34 publications

Examining health care providers’ and middle-level managers’ readiness for change: a qualitative study

Examining health care providers’ and middle-level managers’ readiness for change: a qualitative study

The stipulation‐stimulation spiral: A model of system change

Bridging silos: Delivering integrated care to patients with cancer in Ontario, Canada

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