Articles not relevant for the study were excluded. When inter-organisational collaboration stretches over a wider geographical distance, “differences in the meaning and use of relevant concepts between countries and regions” [53, p. 950] may also occur. To find out more about outcomes-focused approaches to healthcare you can access the Case for outcomes here, [1] U.S. Journal of Clinical Epidemiology, 2009; 62(10): 1006–12. DOI: http://doi.org/10.5334/ijic.3068, Auschra, C. (2018). So has diabetes care for Dutch patients improved? BMJ Open. The issue of barriers that impede inter-organisational collaboration in health service delivery has been addressed in the selected sample of articles in both an empirical (35 studies) and a conceptual way (5 studies, three of them literature reviews, however with the main focus not being on barriers to inter-organisational collaboration). Task-shifting between different categories of health professionals, for instance between general practitioners and nurse practitioners, could also cause friction. 1. Closely related to the notion of barriers are questions relating to their causes [41] and interrelatedness, whereby the existence of one barrier may cause, influence, and/or reinforce other barriers. Development of a program for tele-rehabilitation of COPD patients across sectors: Co-innovation in a network. A taxonomy of accountable care organizations for policy and practice. International Journal of Integrated Care, 2016; 16(1): 1–19. That costs both time as well as trust. For instance, the risk aversion of decision makers, the “not invented here” phenomenon, or a lack of customer orientation [72] could act as further barriers. Public Administration Review, 2012; 72(5): 638–48. Strategic Management Journal, 1996; 17(S1): 55–83. Further themes emerging from the study also included, improving multi-disciplinary communication and increasing CMHT staff knowledge and confidence in CBTp. Fourth, probably more barriers exist than those captured by the papers reviewed here. due to certain institutionalized structures [cf. Strategies for theorizing from process data. The author thanks the two anonymous reviewers of IJIC, Joerg Sydow, two anonymous reviewers and participants of the AOM 2016 meeting (5th–9th August 2016 in Anaheim), as well as participants of the EGOS 2016 sub-theme 52 (7th–9th July 2016 in Naples) for their very helpful comments on earlier versions of this paper. To identify empirical and conceptual work that elaborates on barriers to inter-organisational collaboration in healthcare, a systematic review of literature was undertaken. Additionally, the review only includes the results of the reviewed studies, which could limit its scope (e.g. Barriers to the Integration of Care in Inter-Organisational Settings: A Literature Review. Another major barrier was that the electronic databases used by GPs, practice nurses, care chain partners and hospitals were still not integrated with each other. Furthermore, the incentive to fulfil tasks outside one’s own territory can be very low [55]. Addictive Behaviors, 2000; 25(6): 943–54. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Swedish rehabilitation professionals’ experiences of interorganizational cooperation. Amsterdam: Elsevier. New York: Palgrave Macmillan; 2016. The research design of the empirical studies was mostly qualitative; only two used a quantitative approach and one a mixed-method design. Barriers are not only an issue regarding the subject of inter-organisational collaboration, but also regarding innovation, (strategy) implementation, and organisational change. Public Administration Review, 2008; 68(2): 334–49. They describe these domains as ranging from the macro to the micro level of analysis: the domains of administration, funding, organisation, service delivery and clinical practice [1]. The theory and practice of collaborative advantage. Established hierarchies between professions like physicians and nurses as well as power structures can be a constraint to inter-organisational collaboration. Wicked problems, knowledge challenges, and collaborative capacity builders in network settings. Therefore, more structurally-rooted barriers are able to cause more agentic-driven barriers and vice versa. For instance, Loisel et al. The emerging types of barriers were then assigned to six categories representing analytical themes, derived from the domains regarded important for the integration of care as proposed by Kodner and Spreeuwenberg [1]. Furstenau, D and Auschra, C. Open digital platforms in health care: Implementation and scaling strategies. The case study concluded that although major progress had been made, there were still barriers to a fully-functioning, integrated care system. Minkman, MMN. This first search produced a total of 914 potentially relevant hits. no effect on the collaboration, its transformation or even its termination. The barriers identified in this literature review can be grouped into six main categories that stretch across different domains (see Figure 2). BMC Medical Research Methodology, 2008; 8(45): 1–10. On the other hand, barriers can also emerge more passively behind the back of actors, e.g. Cultural differences between organisations can affect various areas that are relevant for inter-organisational collaboration, e.g. Objectives: The goal of this study was to assess pediatric oncology providers' perceptions of palliative care in order to validate previously identified barriers and facilitators to early integration of a pediatric palliative care team (PCT) in the care of children with cancer. Thus, integration can help to coordinate previously separated tasks of care provision not only across professional or sectoral, but also organisational boundaries [3, 8]. They can provide a helpful framework for the analysis of barriers to the integration of care in inter-organisational settings and are described in the following in greater detail. They were run for matches with synonyms for “inter-organisational” to exclude, for instance, research on neuronal networks (for an overview of the search terms and their applications, see Table 1 in the appendix). DOI: https://doi.org/10.1111/j.1467-9299.2011.01917.x, McPherson, C, Ploeg, J, Edwards, N, Ciliska, D and Sword, W. A catalyst for system change: A case study of child health network formation, evolution and sustainability in Canada. DOI: https://doi.org/10.5334/ijic.3068.s1. This helps to explain why some inter-organisational collaborations that aim for the integration of care make slow or no progress. DOI: https://doi.org/10.1177/0149206307302554, Whiteford, H, McKeon, G, Harris, M, Diminic, S, Siskind, D and Scheurer, R. System-level intersectoral linkages between the mental health and non-clinical support sectors: A qualitative systematic review. Bad experiences in a former or an ongoing cooperation can be a drawback, leading, for instance, to behavioural reservations towards future collaboration among the employees. However, this interpretation may well underlie a bias, as we do not know if the reviewed studies illustrate all existing barriers that hampered a collaboration or if researchers maybe also intentionally (e.g. DOI: https://doi.org/10.1111/1467-6486.00342, Cropper, S, Ebers, M, Huxham, C and Ring, PS. Some were of a political and economic nature, particularly issues in the relationship between the health insurers and the care groups. In care organisations all over Europe, and the world, great work is being done in experimenting with new, innovative models that can solve these issues. DOI: https://doi.org/10.1177/0004867414541683, Cooper, M, Evans, Y and Pybis, J. Interagency collaboration in children and young people’s mental health: A systematic review of outcomes, facilitating factors and inhibiting factors. Beneficial practices of inter-organisational collaboration that help to integrate care include, for instance, the mutual exchange and transfer of information and knowledge, enhanced trust between providers, and the creation of synergy effects [13, 14]. Public Administration, 2011; 89(2): 265–84. Another major barrier was that the electronic databases used by GPs, practice nurses, care chain partners and hospitals were still not integrated with each other. These barriers occur on the inter-organisational domain of analysis and differ from barriers reported in other settings such as markets or hierarchies. They can take on – following the integration needs of care – several directions: vertical collaboration along the chain of health service delivery, including, for instance, collaboration between providers of primary and secondary care, or horizontal collaboration between organisations of the same kind, e.g. Copenhagen: WHO; 2012. In case of power imbalances organisations often start to defend their own resources and authority, which often leads to power conflicts [57, 60]. more actively raised barriers) and structure (more passively induced barriers) are recursively related to each other, mutually (re-) producing and transforming each other [37]. Oxford: Oxford University Press. DOI: https://doi.org/10.1016/S0168-8510(99)00037-8, Glendinning, C. Breaking down barriers: Integrating health and care services for older people in England. In care organisations all over Europe, and the world, great work is being done in experimenting with new, innovative models that can solve these issues. International Journal of Integrated Care, 18(1), 5. by bringing together complementary competences). Discussion and conclusion: The compilation of these results allows for a better understanding of the characteristics and reasons for the occurrence of barriers that impede collaboration aiming for the integration of care, not only for researchers but also for practitioners. DOI: https://doi.org/10.1093/heapro/18.2.135, Dinesen, B, Gustafsson, J, Nøhr, C, Andersen, SK, Sejersen, H and Toft, E. Telehomecare technology across sectors: Claims of jurisdiction and emerging controversies. This barrier was especially mentioned in studies on integrated mental healthcare provision [25, 26]. an organisation that fears a loss of autonomy caused by collaboration). DOI: https://doi.org/10.5334/ijic.28. However, such a view contains pitfalls, as the mere elimination of the factor that causes a barrier does not guarantee that a practice hindered by this barrier will take place. These initial keywords were chosen to cover as many relevant articles as possible. For instance, the particular design of a national health system (e.g. International Journal of Integrated Care, 2012; 12(15): 1–12. Thomas Allvin is Executive Director for Strategy and Healthcare Systems at EFPIA. A barrier itself can show up as a symptom of one or more underlying causes that constitute the barrier [41]. Auschra C. Barriers to the Integration of Care in Inter-Organisational Settings: A Literature Review. Although such barriers are mentioned in various studies of integrated care in inter-organisational settings – partly as the main focus and partly as a by-product while elaborating on other facets of inter-organisational collaboration – so far no systematic review of the relevant literature has been compiled. Popp, J, MacKean, G, Casebeer, A, Milward, HB and Lindstrom, R. Inter-organizational networks. The reviewed literature provides insights on the relationships between barriers as well as their causes. In their study Tsasis and colleagues report on a healthcare professional who states that he does not necessarily understand exactly how other organisations in the same community contribute to the care of clients. The care groups negotiate the content and price of a comprehensive package of diabetes care, which makes it possible for the health insurer to buy care as one, single service, even though it will be delivered by different groups of healthcare professionals in different settings. The following paragraphs give an overview of the barriers analysed. Obviously, inter-organisational collaboration can include or overlap with inter-professional and intra-organisational collaboration, especially in the context of integrated care. Around 75% of healthcare spending in Europe is directed towards managing and treating chronic diseases. Some studies addressing barriers to inter-organisational collaboration use no theoretical conceptualization at all [e.g. 47], and no general approach exists to conceptualize barriers that impede inter-organisational collaboration. Resistance to change: Often, organisational members are not willing to accept changes connected to the implementation of inter-organisational collaboration, especially if they do not see the usefulness of the collaboration or fear the loss of their own professional existence [54]. For instance, the relationship between factors working as barriers to collaboration and the relationship to facilitators for collaboration (that help to lift the barrier) is still unclear. This represents the barrier “lack of organisational resources and funding” (meso-level, agent-driven barrier). This could be an indicator that many reasons for the slow progress or even failure of the delivery of integrated care across organisational boundaries can be found in the last domain. Also, the range of the cases included (omitting for the most part, for instance, inter-organisational collaborations in the third world) involves limitations to this interpretation. DOI: https://doi.org/10.1016/S0168-8510(99)00037-8, https://doi.org/10.1016/S0168-8510(02)00205-1, https://doi.org/10.1097/00004010-199502010-00007, https://doi.org/10.1007/978-1-137-37003-7, https://doi.org/10.1097/00004010-200201000-00003, https://doi.org/10.1007/s10926-010-9281-1, https://doi.org/10.1097/HMR.0b013e31822aa443, https://doi.org/10.1080/13561820500081745, https://doi.org/10.1093/oxfordhb/9780199282944.001.0001, https://doi.org/10.1111/j.1540-6210.2007.00866.x, https://doi.org/10.1007/s11301-014-0109-5, https://doi.org/10.1016/B978-008044198-6/50038-3, https://doi.org/10.1016/j.jclinepi.2009.06.005, https://doi.org/10.1007/s11414-014-9448-1, https://doi.org/10.1080/13561820902921811, https://doi.org/10.1016/j.socscimed.2006.07.031, https://doi.org/10.1108/14777261011047354, https://doi.org/10.1111/j.1447-0748.2005.00198.x, https://doi.org/10.1016/S0306-4603(00)00127-1, https://doi.org/10.1080/1356182021000044166, https://doi.org/10.1111/j.1467-9299.2011.01917.x, https://doi.org/10.1186/s12913-017-2018-5, https://doi.org/10.1111/j.1540-6210.2012.02595.x, https://doi.org/10.1007/s10926-009-9205-0, https://doi.org/10.1007/s10926-005-8036-x, https://doi.org/10.1186/s12884-017-1381-x, https://doi.org/10.5465/AMR.2009.44885978, https://doi.org/10.1177/003803857200600101. For instance, Dinesen and colleagues [61] show that hospital and district nurses are sometimes unable to develop a common network vision, as they lack knowledge of each others’ competences. Clinical guidelines are often established for major chronic diseases, but the guidelines can vary between regions and countries, and they are not always implemented in the same way (or at all). DOI: https://doi.org/10.1177/0149206314563399. Passively emerging barriers like historical developments or the existence of national borders, in contrast, are caused mostly by structural and institutional arrangements. Kodner and Spreeuwenberg (2002) have proposed five domains, representing certain fields of social action that are relevant for the integration of care, thereby also applying to the integration of care in inter-organisational settings. Fourthly, the partners follow certain rules, norms, and structures within the relationship – rendering the relationship either formal or informal [34]. Some studies rely on leadership concepts [48], neo-institutional theory [49], a complex adaptive systems perspective [50], professional identities [51], or innovation approaches [27]. Based on this review, several areas for further research can be identified: first, our knowledge regarding barriers to the integration of care in inter-organisational settings would benefit from more systematic attention to existing organisation and network theories that address such barriers, even if only implicitly. It sounds self-evident, but several complicating factors can make integrated care difficult to implement in practice. Additionally, hospital providers often have a good reason not to foster collaboration with community social care providers, as a following shift from patients to these providers would make hospital beds redundant, leading to a loss of resources for the hospitals (organisational vs. collective interests, meso-level, agent-driven barrier). International Journal of Integrated Care. Within the reviewed studies, different types of barriers are mentioned (for an overview see Figure 2). Introduction: In recent years, inter-organisational collaboration between healthcare organisations has become of increasingly vital importance in order to improve the integration of health service delivery. DOI: https://doi.org/10.5334/ijic.511, Sydow, J, Schreyögg, G and Koch, J. Because these categories serve mainly an analytical purpose, it is likely that the kinds of barriers and their domain of occurrence overlap (for instance, bad collaboration experiences can affect individuals entrusted with service delivery as well as organisations). One such example is the implementation of integrated care for Type 2 Diabetes in the Netherlands, a model that was recently subject to a case study under the EU-funded Project INTEGRATE. The barrier “different professionalisation” was reported most frequently (n = 20), followed by “lack of leadership and coordination” (n = 13) and “organisational vs. collective interests” (n = 13). DOI: https://doi.org/10.1111/j.1540-6210.2007.00866.x, Berends, H, van Burg, E and van Raaij, EM. DOI: http://doi.org/10.5334/ijic.3068, Auschra, Carolin. Lack of organisational resources and external funding: Sometimes organisations lack the resources needed to initiate and develop inter-organisational collaboration [e.g. DOI: https://doi.org/10.5334/ijic.582, Hearld, LR, Alexander, JA and Mittler, JN. DOI: https://doi.org/10.1007/s10926-005-8036-x, van Hook, MP and Ford, ME. e.g. Barriers to the Integration of Care in Inter-Organisational Settings: A Literature Review. Axelsson, R and Axelsson, SB. Different search terms were applied, obtained from the definitions of inter-organisational collaboration, barriers, and integrated care, and including various synonyms. In primary healthcare, a key barrier to effective and timely care was the lack of availability of general practice-based spirometry together with appropriate use of spirometry by general practitioners (GPs) and practice nurses to both diagnose and manage a patient with COPD: 47]. Furthermore, within different organisations often divergent formal timetables and time horizons [47], different decision-making structures [56], and different views about employment, accountability and hierarchies [55] exist, affecting inter-organisational collaboration. 2018. A general lack of funding for collaboration, i.e. DOI: https://doi.org/10.1186/s12913-017-2018-5, Bang Christensen, JK. Collaboration between organisations belonging to regions with a long history of the fragmentation of care, e.g. Taking a visible barrier as a starting point, it is advisable to look for related barriers which may prove to be the cause of the first barrier or influence it. The end goal is to provide higher quality care, resulting in better health outcomes for the patient, and a better patient experience of the care journey, often at the same or even lower cost. A comparative study of integrated care development and delivery. Surprisingly, although often used, the term “barrier” is seldom defined. DOI: https://doi.org/10.1111/1475-6773.12234, Wadmann, S, Strandberg-Larsen, M and Vrangbaek, K. Coordination between primary and secondary healthcare in Denmark and Sweden. Leading institutions, practitioners and researchers have reached a consensus that health service delivery profits from integration [1, 2, 3, 4] “across time, place and discipline” [5, p. 1]. International Journal of Integrated Care, 2009; 9(3): 5–22. Fifthly, the participants of inter-organisational relationships can also be competitors, being for-profit, and/or public, non-profit organisations [23]. Lack of mutual understanding: Inter-organisational collaborations do not materialize, are hampered, or fail if one partner has little understanding of the goals, procedures and behaviour of the other(s). The present review focuses on inter-organisational collaboration as one governance form (beside markets and hierarchies) that enables the integration of care [3]. Hopefully, however, these findings will give new input to research and can help healthcare professionals, managers, teachers and policy makers to identify, avoid and overcome barriers to integrated care in inter-organisational settings. The barriers approach to innovation. They may have limited resources for this kind of care, including space and staffing of mental health providers. theoretical approach of the articles, barriers cited within these articles). Moreover, chronic disease accounts for 86 percent of our nation’s healthcare costs.An integrated delivery system and an accountable care organization with two large academic medical centers and six commu… DOI: https://doi.org/10.1111/j.1540-6210.2012.02595.x, Stahl, C, Svensson, T, Petersson, G and Ekberg, K. A matter of trust? Around 75% of healthcare spending in Europe is directed towards managing and treating chronic diseases. Sarah Wadmann, Researcher, PhD, VIVE, Denmark. Second, empirical research should disentangle the interplay of barriers and their context-dependence more carefully, as well as their underlying causes and the visible symptoms [see also 41 for barriers to innovation]. The fifth domain relevant for the integration of care is the clinical domain, involving, for instance, common professional languages, agreed understandings, practices and standards related to certain diseases, and ongoing communication with patients [1]. in the public sector, is perceived as a main barrier to inter-organisational collaboration and causes high uncertainty for actors willing to collaborate [9]. In a second step, irrelevant hits were sorted out from the potentially relevant articles by reading the abstract of each article. 6th November 2014. Cultural distance between organisations: Organisations develop their own specific cultures, which can create barriers to inter-organisational collaborations if organisations are not capable of managing these differences. Organizational structure, environment and performance: The role of strategic choice. Furthermore, they fear cost shifting connected to the entry into an inter-organisational collaboration, e.g. Hueske, A-K and Guenther, E. What hampers innovation? Journal of Occupational Rehabilitation, 2011; 21(3): 441–8. International Journal of Integrated Care, 2010; 10(3): 1–9. This would have a huge potential for increasing the quality of care given to patients, and for making substantial efficiency gains in health expenditure – a healthy investment, by any standard. Several empirical works address barriers to the delivery of integrated care in inter-organisational settings, but mostly focus on aspects specific to their case [11, 27] and lack theoretical embedding. DOI: https://doi.org/10.1016/S0306-4603(00)00127-1, Goldman, HH. Langley, A. Of decision making or the existence of national borders, in some cases, the implementation! Lead to the entry into an inter-organisational collaboration domain where the Management of a political economic! 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