Physicians’ Perceptions of Integration in Three Western Canada Health Regions

ORIGINAL ARTICLE

Physicians’ Perceptions of Integration in Three Western Canada Health Regions by Olive H. Triska, John Church, Douglas Wilson, Rick Roger, Robert Johnston, Ken Brown, and Tom W. Noseworthy Olive H. Triska, PhD, is an Adjunct Assistant Professor at the University of Alberta in the Department of Public Health Sciences. Her research interests include primary health care, evaluation, and governance and accountability. John Church, PhD, is Associate Professor, Centre for Health Promotion Studies and Department of Political Science, University of Alberta. His research interests include public policy decision-making, health reform and primary health care. Rick Roger, MHSA, received a Masters in Health Administration from the University of Alberta in 1980. He was Chief Executive Officer of the Vancouver Island Health Authority until October 2004. Prior to his return to Victoria he was the CEO of the Vancouver/ Richmond Health Board. From 1985 to 1996, he was with the Greater Victoria Hospital Society as the Vice President of Operations and Finance. Robert Johnston, MD, became a Senior Vice President Advisor Patient Advocacy in September 2004 following his role as Chief Medical Officer from 2002-2004 in the Calgary Health Region. His current responsibilities include: leading a team to investigate, develop and enhance patient experience at Calgary Health Region, complement patient safety and quality improvement in relation to patient experience, develop a system to improve patient/ clients/ caregivers navigation through the complex health care system, and patient advocate at Executive Management Team. Ken Brown, MHSA, is Director of Corporate & Legislative Affairs with the David Thompson Health Region. T. W. Noseworthy, MD MSc MPH FRCPC FACP FCCP FCCM CHE. Dr. Tom Noseworthy is Director, Centre for Health and Policy Studies, Professor (Health Policy and Management) and Head, Department of Community Health Sciences, University of Calgary. His research focuses on optimizing clinical practice behaviours and patient outcomes and improving quality management of waiting times for scheduled services. Douglas Wilson, MD, is a Professor Emeritus with the Department of Public Health Sciences, Faculty of Medicine and Dentistry, University of Alberta. His interests are in population health, health policy, and health promotion/disease prevention, examined from multidisciplinary perspectives. (No photo available)

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Abstract Over the past decade, provincial governments have embarked on ambitious plans to better integrate their healthcare systems, through the introduction of regional governance and management structures. The objective of this study was to examine physicians’ perceptions of the current level and facilitators/barriers to integration in three Western Canada Health Regions. Three approaches to integration were investigated: functional, clinical services, and physician system integration. Physicians perceived that functional integration within each region was questionable. Clinical services were the least integrated approach. Physician system integration was rated highest of the approaches, particularly adherence to clinical practice guidelines usage. Physicians’ perspectives of integrated health delivery systems do not appear to be influenced by regional size, maturity, urbanicity or facilities. Facilitators of integration were communication among health professionals and service providers, and using a multi-disciplinary team approach in delivery of healthcare in both regions. Barriers to integration were organizational culture, access to specialists and clinical services, and health information records. On a scale of 1-5, all three regions are at the beginning of an integrated health delivery system. Three global suggestions were provided to further integration of health delivery services: physicians should be involved in decision-making process at the Board level, clinical services should be patient-centred, and physicians endorsed the use of multi-disciplinary teams.

P

Introduction rovincial governments have embarked on ambitious plans to reform their health systems through the introduction of regional governance and management structures. Underpinning these reforms is the idea that enhanced integration of the health delivery system (IHDS) will be more efficient and effective and better meet the needs of the populations served.

Over the past decade, the federal government has conducted a number of studies on healthcare reform and policy.1-3 A common theme is that new and innovative ways of delivering services are needed. IHDS is a key approach that encompasses organizational change, health providers, clinical services, information technology, and vertical integration. Regionalization of governance, management, and service delivery is most often identified as the best means to realize identified major goals of reform, including integration of service delivery. Integration of health delivery systems has received a great deal of local, national, and international attention.4-9 It is seen as a way to build an efficient and effective healthcare system that meets the needs of the populations. While there are many definitions of integration, the one adopted for this study is “An integrated healthcare system combines physicians, hospitals and other medical services within a health plan… to provide the com-

plete spectrum of medical care for its customers.”8 Primary care forms the foundation, the consumer/client/patient drives the IHDS in terms of access and capitation, and healthcare providers are involved in decision-making, including the development of clinical practice guidelines and care pathways. Given this, it may be argued that physicians are in a pivotal and decision-making role able to facilitate integration, and should be included in the governance and leadership of a health region, acting as a potential indicator of enhanced integration.8 Accordingly, physicians should be involved in decision-making changes in the region because buy-in is significantly higher and they may voluntarily become more involved with the IHDS process and quality control. A review of regionalization in Canada suggests that, for the most part, physicians were not involved initially in decision-making, in determining what reforms to implement or how to implement them. Physician associations were cautious about regionalization in most provinces, when it was first initiated. Subsequently, regional structures have begun to involve physicians in shared decision-making through formal management and clinical roles, and through collaborative partnerships in the delivery of healthcare services.9,10 However, physician services are not currently included in regional funding envelopes. Financial incentives and information systems have been identified as critical elements for integration.11 While regional data repositories in a number of jurisdictions now have the capacity to generate information at a population level, the integrated patient record still remains an elusive goal. Some argue that the goal of achieving full integration in Canada has not been met.12 This study is part of a larger work on integration involving multiple stakeholder groups: community partners, boards of directors, administration

(corporate staff, administrators, directors, managers), nurses, other health professionals (pharmacists, dietitians, social workers, therapy services), and patients (acute care, long term/residential care, community-based continuing care). The purpose of this article is to discuss physician perceptions of integration in three health regions in two Western Canada provinces – the Vancouver Island Health Authority (VIHA) in British Columbia, and the Calgary Health Region (CHR) and David Thompson Health Region (DTHR) in Alberta. Each region has unique characteristics, which are discussed below.

The DTHR website describes the region as “… a mainly rural region spanning the centre of the Province between Edmonton and Calgary. Third largest health region by population, the DTHR serves 282,900 residents, covers 60,000 sq. km of territory and employs about 8,000 staff.”16

Background Integration of health services in British Columbia began in the mid-1980s with the formation of the Greater Victoria Hospital Society (GVHS) by merging the Royal Jubilee Hospital (RJH) and the Victoria General Hospital (VGH) in Victoria, BC. In 1997, the GVHS amalgamated with seven other major healthcare provider organizations. In December 2001, the government of BC reorganized the province’s network of 52 Regional health authorities into 15 health service delivery areas in five geographic health authorities and one provincial health service authority that coordinates and/or provides provincial programs and specialized services.14 The purpose for this redistribution of services was to improve efficiency, strengthen accountability, and allow better planning and service coordination for patients. The VIHA provides services to approximately 703,000 people from Vancouver Island, the Gulf Islands, and Central Coastal regions.

The three regions have commonalities. They have provincially determined geographic boundaries; their mission statements declare their commitment to health services that are appropriate, affordable, accessible, accountable, and that promote healthy living; and, further, they explain that their services will be patient-centred.

The Alberta government mandated regionalization in 1994 with the intention of cutting costs by abolishing the existing 250 hospital, continuing care, and public health boards and establishing 17 regional and 2 provincial boards. In April 2003, geographic boundaries were changed to create nine health regions in the province. The CHR provides services to approximately 1.1 million people in metro Calgary and the surrounding area.15

Each region was selected specifically for its characteristics and differences. The selection criterion was: differing periods of regionalization; variation in population size and distribution; different geography; and, willingness to participate.

Each region has distinct differences. VIHA services an urban and rural population on Vancouver Island and part of the West Coast mainland. The population is disbursed over a large geographic area that is isolated in parts of the region (e.g., Port Hardy, Uculet). CHR is a metro region with a small rural component west of Calgary along the Rocky Mountains. The majority of the population resides in Calgary. Since DTHR’s boundaries span the area from the Saskatchewan to the British Columbia border, this region is mainly rural. Many health centres and services are located in a corridor along the highway that connects Red Deer with Edmonton and Calgary. Method This study examined physicians’ perceptions of integration in three health regions, with emphasis on the components of integration described in the literature.7-9,17 Two overall research questions focused this study. From a physician’s perspective: 1) What is the current state of integration?

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2) What are the facilitators and challenges to integration? The components of integration were functional integration, clinical services integration, and physician integration.7,9 Functional integration components included organizational culture, strategic planning, and financial management. Clinical services integration measures included access to health providers by the population, health information records, and shared support services for providers. Physician integration concepts examined were adherence to clinical practice guidelines, and shared accountability. Barriers identified in each category ranged from lack of understanding of integration (functional), disbursed geography (clinical services), and fear and distrust (health professionals).17 A published questionnaire was used as a template for numeric data collection.9 It was adapted for Canadian context by having physicians review and edit the content. Additional items were added, and others deleted, if inappropriate for Canadian healthcare. The questionnaire included 51 Likert-type questions, on a 5-point scale. The response choices were strongly agree (5), agree (4), neutral (3), disagree (2), strongly disagree (1), and do not know (0). Two global items dealt with organizational and clinical services integration. Six open-ended items completed the questionnaire. Two physicians reviewed the questionnaires and verified content and context validity. Construct validity was measured using factor analysis that resulted in a unidimensional factor (integration) using imaging extraction and the varimax rotation method. Two reliability indexes were calculated on the physicians’ questionnaire. Cronbach’s alpha for internal reliability was 0.92. The intraclass correlation was calculated to determine the consistency of physicians’ responses holding the items constant. The intraclass correlation using a two-way mixed effects model (consistency) was 0.92 (95% CI 0.91-0.93).

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TABLE 1. Demographics of the Physician Sample N

Response Rate N (%)

Sex

Years of Practice (Mean)

Family Medicine (%)

Specialized Family Medicine (%)

Specialists (%)

VIHA

485

181 (37)

Male = 70% Female = 30%

21

41

4

54

CHR

505

215 (43)

Male = 62% Female = 38%

21

34

7

58

DTHR

400

170 (42)

Male = 81% Female = 19%

21

55

7

38

A random sample was drawn from provincial physician registries in VIHA and CHR. Two rounds of mail-out questionnaires were sent to practicing physicians in VIHA and CHR in October and November 2003. In DTHR, all physicians in the region were included and two mailings of questionnaires were sent in April 2004. Sampling was inflated by 40% to compensate for a potentially low response rate. Each questionnaire was assigned a unique identifier according to the region. Numerical data were entered into Statistical Package for the Social Sciences (SPSS) V. 12.0. Text was entered into Microsoft EXCEL. Descriptive statistics (mean, median, range, frequency) and measures of dispersion (standard deviation, standard error of the mean) were calculated for each item. Text from the open-ended questions was analyzed using the integration categories as described in the questionnaire, using codes and performing a content analysis. The transcripts were verified by having another researcher review the analysis. Results The results are presented using the integration categories (functional, clinical services, and professional) starting with a description of the physicians. A summary table (Table 2) provides a representative sample of quantitative items (34 of 58) and responses in each category. Questions in Table 2 were selected to illustrate the range of responses; that is, the most positive

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(mean greater than 3.5) and negative (mean less than 2.1) for each sub-category. Questions will be referred to in Table 2 according to their number (e.g., Q. 2) to link them to the results. Six open-ended items responses complete the results section (Table 3). Demographics Approximately 1,400 questionnaires were mailed to physicians in the three regions (Table 1) in two mailings three weeks apart. The response rate was identical in the CHR and DTHR regions (43%), but lower in the VIHA (37%). The distribution of responses from males and females was uneven, especially in the DTHR. Physicians in all three regions were in practice for more than 21 years. The CHR had the greatest number of specialists (58%) whereas DTHR had the greatest number of family practitioners (55%). Functional Integration Three sub-categories of integration were explored: organizational culture, strategic planning, and financial management. Perceptions of organizational culture varied across the three regions. Visibly posting a common statement of the vision and mission of the region was rated below 3.0 across all three regions (Q. 1), indicating that physicians did not totally agree with this statement. The medical staff of departments appeared to have a commitment to the region, overall (Q. 2). However, except for DTHR (Q.3), physicians felt that regions did not understand their needs to manage patients.

For strategic planning, physicians perceived that government constrained the development of resource plans (Q. 4). There was agreement that government controlled the regional business plans, across the three regions (Q.5). Conversely, physicians felt that a consistent strategic plan was not developed (Q. 6). Overall, financial management was not viewed positively, with the exception of DTHR (Q.7). It was felt that Boards did not allocate resources well and did not understand what physicians needed to treat their patients (Q. 8). Too many resources were channeled into inpatient services (Q. 9). Physicians agreed that the emphasis is on controlling costs rather than on patient satisfaction (Q. 10), evidence-based medicine (Q. 11), and community health status (Q. 12). Clinical Services Integration The DTHR viewed clinical services integration more positively than did VIHA and CHR. Accessing health services was a greater concern in VIHA and CHR than in DTHR. Physicians in VIHA and CHR disagreed that geographic practice sites met their clinical practice needs (Q. 13) and individual practice sites (Q. 14.). There was inadequate access to clinical services in VIHA and CHR (Q. 15). Physicians in all three regions were undecided on the issue of duplication of clinical services in the region (Q. 16). Physicians in DTHR felt they had adequate access to clinical services for their patients (Q. 17). Physicians in all three regions disagreed that clinical services were well coordinated within departments (Q. 19). Overall, clinical services were not well coordinated (Q. 20). Physicians were disappointed with integrated health records. Patients could not make an appointment for a visit to a clinician, a diagnostic test, or a treatment with one telephone call in VIHA and CHR (Q. 20). In all three regions, physicians said that patients repeated their health history with each provider encounter (Q. 21). Integrated clinical data was shared across departments

only in DTHR (Q. 22). Physicians disagreed that a single medical record was available for all patients (Q. 23). Providers did not have rapid access to patients’ relevant clinical and non-clinical data at all care delivery sites (Q. 24). Physicians in all three regions stated that there is no single region-wide management information system for all facilities (Q. 25). Clinical practice guidelines (CPGs) were generally well accepted. Physicians explained that CPGs were used to treat various medical conditions (Q. 26) and deliver patient care (Q. 27). CPGs were used in all facilities providing patient care in DTHR, but not in VIHA and CHR (Q. 29). Physicians have access to CPGs to facilitate evidence-based medicine from the point of care in CHR, but less so in VIHA and DTHR (Q. 29). Professional Integration Physicians’ perceptions of professionalism varied. DTHR physicians stated that they felt they played a key leadership role in the region more so than physicians in VIHA and CHR (Q. 30). Physicians felt that they were part of a region-wide staff (Q. 31). However, they did not feel strongly that they were part of a team or process aimed at integrating healthcare delivery (Q. 32). Global Perceptions From the perspective of the almost 600 physicians in three diverse health regions who participated in this study, the current state of integrated service delivery is unsatisfactory. This finding is perhaps best illustrated by results of the two global questions relating to overall organizational (Q. 33) and clinical services (Q. 34) integration. Physicians disagreed that integration was occurring in these two broad areas, with scores across the three regions ranging from 2.2 to 2.7 on a 5-point scale. Open-Ended Items Six open-ended items were included in the questionnaire to provide additional insight. Each item linked to Likert-type questions dealing with access, facilitators, and barriers to IHDS. Question 1 sought examples of how healthcare

providers work well together (Table 3). In all three regions, physicians rated the multi-disciplinary team approach in hospitals and the community as very positive. As well, physicians in all three regions said that patient services (e.g., palliative care, emergency, home care, and mental health) were well coordinated, and that communication among physicians and other healthcare providers worked well. The second question asked for examples of how healthcare providers do not work well together. Staff issues such as shortage of specialists to deliver healthcare, and staff burnout were frequently cited in VIHA. Patient transition, that is, discharge issues, and transition to residential care were difficult in all three regions. Resource allocation in the form of protectionist attitudes and resource sharing was unsatisfactory, and integration of health records – particularly transfer of patient health records to family physicians in all regions – was poor. Question 3 asked physicians for examples of well-coordinated clinical activities and services. VIHA physicians cited patient programs such as home care, neonatal care, mental health, and renal services. Examples of well-coordinated acute care services were the emergency department, surgery, oncology, and psychiatry. CHR physicians spoke highly of the coordination of services in acute care settings, particularly trauma teams, and cardiology. Patient programs such as pediatric specialties programs were highly rated, as were diabetes clinics and breast clinics. DTHR physicians said that emergency services and physiotherapy services were not well coordinated. Question 4 asked physicians for examples of clinical activities and services that are not well coordinated. VIHA physicians were very concerned with the difficulty in accessing specialists for patient care. The lack of coordination of patient health records was another major concern among physicians. Among clinical services, CHR physicians identified patient services, specif-

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TABLE 2. Physician Questionnaire Items

Physician Questions Items N

VIHA Mean Std. Dev.

N

CHR Mean Std. Dev.

N

DTHR Mean Std. Dev.

FUNCTIONAL INTEGRATION Organizational Culture 1. Common statement of vision and mission are visibly posted in all regional facilities. 2. The medical staff of departments have a high degree of commitment to the region overall. 3. The region understands what physicians need to manage their patients.

169 180 178

2.01 3.08 2.06

3.39 1.34 .98

172 207 213

2.91 3.33 2.38

1.04 1.06 1.15

158 150 163

2.94 3.83 3.59

.94 .76 .98

Strategic Planning 4. The government constrains the development of resource plans. 5. The government controls the region’s business plans. 6. The Board has developed a consistent strategic direction.

180 180 179

3.64 3.50 1.89

1.43 2.04 1.32

185 182 177

3.90 3.58 2.63

.86 .94 1.00

136 137 141

3.77 3.77 2.96

.88 .80 .96

Financial Management 7. The Board allocates resources well. 8. The region understands what physicians need to provide resources for their patients. 9. Too many resources are allocated to support inpatient activities. 10. Controlling costs are emphasized instead of patient satisfaction. 11. Controlling costs are emphasized instead of evidence-based medicine. 12. Controlling costs are emphasized instead of community health status.

176 180 179 180 176 180

2.02 2.02 2.26 4.01 3.86 3.78

1.26 1.10 1.16 1.04 1.05 1.208

186 210 200 207 204 202

2.52 2.38 2.74 3.74 3.62 3.69

.92 1.08 1.03 1.02 1.07 .96

126 110 137 148 159 154

3.24 .88 2.45 .97 3.25 .95 2.47 .84 3.36 1.05 3.31 .97

CLINICAL SERVICES INTEGRATION Access 13. Practice sites provide geographical coverage for physicians to meet needs across the region. 14. Practice sites provide geographical coverage for physicians to meet needs across individual practice sites. 15. There is adequate access to clinical services. 16. There is little duplication of clinical services in the region. 17. There is adequate access to clinical services for my patients. 18. Clinical activities and services are well coordinated within departments. 19. Clinical activities and services are well coordinated.

178 172 180 180 178 180 180

2.71 2.51 2.21 2.88 2.18 2.53 2.38

1.27 1.40 1.05 1.202 1.026 1.24 1.06

192 177 212 199 209 194 198

2.74 2.84 2.11 3.04 2.23 2.51 2.36

1.01 1.01 1.02 1.06 1.13 1.07 .93

165 151 134 165 152 129 139

3.37 2.95 3.30 .92 3.29 .87 2.99 1.34 3.17 .98 2.12 .97 2.67 .91

Health Records 20. Patients can make an appointment for a visit to a clinician, a diagnostic test or a treatment with one phone call. 21. Patients repeat their health history for each provider encounter. 22. Integrated clinical data are shared across departments. 23. A single medical record exists for all patients regardless of the point of entry into the region. 24. Providers have rapid access to patients’ relevant clinical and non-clinical data at all care delivery sites. 25. There exists a single region-wide management information system in the region for all facilities.

181 181 179 178 179 178

2.20 3.64 2.18 1.84 1.75 1.48

1.29 1.125 1.14 .90 .84 .91

200 209 191 201 206 179

2.14 3.97 2.28 1.69 1.83 1.80

1.01 .76 .92 .84 .82 .83

159 151 155 81 159 160

3.86 1.05 3.08 1.12 3.65 .88 2.96 .86 1.99 .97 1.98 .98

Clinical Practice Guidelines (CPGs) 26. CPGs are used for various medical conditions. 27. CPGs are used to deliver patient care. 28. CPGs are used in all facilities that provide patient care. 29. Physicians have access to CPGs to facilitate evidence-based medicine at the point of care.

180 180 180 180

3.42 3.13 2.11 3.11

1.06 1.15 1.53 1.21

211 208 170 204

3.67 3.49 2.92 3.59

.739 .810 .92 .90

149 158 159 131

3.32 3.59 3.54 3.18

PROFESSIONALISM 30. Physicians play a key leadership role in the region. 31. Physicians are part of a region-wide staff. 32. As a physician, I feel part of a team or process aimed at integrating healthcare delivery.

176 179 181

2.48 3.30 2.55

1.23 1.38 1.15

210 216 214

3.03 3.88 2.88

1.16 1.02 1.20

165 170 150

3.47 4.91 3.96 1.25 2.89 .93

GLOBAL ITEMS 33. How would you rate the level of integrated delivery of health services from an organizational perspective? 34. How would you rate the level of integrated delivery of health services from a clinical services perspective?

145 145

2.53 2.39

.89 .89

176 175

2.46 2.35

.79 .79

82 82

2.71 1.00 2.72 .93

ically mental health and specialist waitlist services, as poorly coordinated. In DTHR, patient transfer issues, including transfer of health records, discharge, and patient follow-up, were not well coordinated. The fifth question dealt with community services offered by other service providers and community organizations to improve the community. Community services identified in VIHA were voluntary charitable foundations and community health education programs. A 22

public health program – community health immunization – was identified as a way to improve the community. In CHR, home care programs and greater accessibility to community care were identified as ways to improve continuing community care. Sharing of patient health records with other healthcare service providers was singled out as a means of improving patient service delivery. DTHR physicians explained that their health region works with other service providers and community organizations to provide mental health

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.95 .79 .77 .89

and long-term placement of patients into residential care. The last question concerned the level of participation of other health professionals (nurses, pharmacists, dietitians, social workers, therapists) in the decision-making process for client/patient care. One VIHA physician explained, “Only if they will show the responsibility of the consequences of the decision taken.” While physicians said that health professionals should be involved in the decision-making process, they

TABLE 3. Open-Ended Questions from the Questionnaire 1. 2. 3. 4. 5. 6.

Can you give some examples of how the healthcare providers work well together? Can you give some examples of how the healthcare providers do not work well together? Can you give some examples of clinical activities and services that are well coordinated? Can you give some examples of clinical activities and services that are not well coordinated? Can you think of ways that the health region works with other service providers and community organizations to improve your community? What level of participation should other health professionals (pharmacists, nurses, social workers, therapists) have in decision-making?

also agree that the physicians should ultimately make the decision about a patient’s care. In CHR, physicians endorsed a multi-disciplinary team approach with emphasis on the level of expertise and responsibility accorded to each health professional. One physician said, “Physicians alone should make diagnoses and decisions. They take the …legal responsibility for the patient.” Physicians in DTHR favoured having other health professionals involved in decision-making, in their specific area of expertise and accepting responsibility commensurate with their expertise, but said that the activities should be physician-directed. Discussion Our findings suggest several important observations about physicians’ perspectives on integration in each of the three regions. VIHA physicians did not perceive that they played a key leadership role in the region. This perceived lack of direct involvement in the decision-making process is reflected in the neutral response to issues dealing with government. Phyicians felt that although the system is patient-driven, the focus is on controlling costs rather than on patient satisfaction, evidence-based medicine, or community health status. Of the three areas of integration – functional, clinical, and professional – clinical services were the least integrated, especially health records for patients and across the region. Availability of patient health records was unsatisfactory as was coordination of clinical activities. Physicians did not agree that they were part of a team to deliver health services, and generally agreed that the region did not understand what resources were needed for their patients. However, there was

one area where progress is being made, and that is reflected in the high level of acceptance of CPGs by physicians. CHR physicians were neutral about their leadership role in the region and about being part of a team aimed at integrating healthcare delivery. Physicians did perceive that they were part of a region-wide staff. They were not supportive of the Board decisions, particularly around developing a consistent strategic direction, considering internal capabilities when developing a regional strategy, and allocating resources. Access to medical records and information management systems in the region was viewed poorly, and clinical activities and services were of concern because they were not well coordinated. DTHR physicians were neutral about their involvement in leadership and about being part of a multi-disciplinary team. However, they did feel part of a region-wide staff (organizational culture). Government involvement in priority setting and resource planning was considered favourably, but accessing health records posed a problem. As was the case with VIHA, CPGs were well accepted by physicians in DTHR. Physicians from all three regions agreed that communication among themselves and other health professionals facilitated integration. Multi-disciplinary teams were viewed positively for delivering healthcare within the region. Conversely, a barrier to integration was physicians’ lack of involvement in decision-making. Physicians were discontented with what they perceived as the government’s attitude towards controlling costs at the expense of patient satisfaction and community health.

It should be acknowledged that integration of health services within (and between) regions is a “work-inprogress.” Nevertheless, these findings indicate important issues to be considered by health service managers and health professionals. First, for integration to occur, physicians should be involved in the decision-making process at the Board level. This is an indicator of an integrated mature health region.8 In the data we examined, physicians did not perceive this to be occurring. Second, clinical services in the region should be patient-centred and patient-driven for physicians to deliver healthcare to the population, by adopting a primary care model of health delivery.18 In none of the cases examined did physicians strongly perceive this to be taking place. Third, physicians embraced the delivery of health services using a multi-disciplinary team approach. However, the nature of the perceived team (physician-driven) may be at odds with the broader consensus within the health field of how teams should function. In part, this reflects the continuing structural barrier to which physicians allude: legal liability. Until this barrier is removed and other challenges such as method of payment and scope of practice are addressed, physicians are unlikely to alter their view on the nature of teams. Despite this, an approach that encourages physicians to work collaboratively with other providers should be nurtured and fostered within the region in acute care, community continuing care, and residential care.19 Limitations As with most studies, this project was not without limitations. There were issues with internal and external validity. With internal validity, there were

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concerns about selection and testing. Selection of physicians to participate in the study was a random sample drawn from two provincial physician registries. Although selection criterion was that physicians were in active clinical practice, a small number of physicians on the registry were retired or deceased. With oversampling of 40%, the sample size and two mail-outs of the questionnaire, the sample did not meet the predetermined calculations for effect size and power. The number of non-respondents was of great concern. We cannot conclude that non-responding physicians would have been unbiased in their responses. As for testing the questionnaire, which originated in the U.S., it was adapted and modified for Canadian content.9 During the development of the questionnaire, we were mindful of the differences between the U.S. and Canadian healthcare systems. Many items were reworded for Canadian content, while at the same time trying to maintain the underlying construct. Another limitation was the timeframe for gathering the data. Because of the Alberta regional boundary changes, the DTHR requested that data collection be scheduled one year after the boundary change. The region felt that one year was needed to stabilize the organization.

Validity studies were done (factor analysis), but a larger sample size is needed to use this questionnaire confidently (approximately 1,500). On a positive note, the reliability (Cronbach’s alpha and intraclass correlation) was above 0.92, indicating that the results could be replicated in a similar population under similar circumstances. Conclusions A hallmark of a well-integrated health region is the involvement of physicians at the decision-making table of the organization.8 The current study examined physicians’ perceptions about integration within three regional health authorities of varying characteristics within Canada. The results suggest that while communication, teamwork, and uptake of CPGs appear to have been enhanced through regionalization, physicians’ perceptions of involvement in decision-making, integration of clinical services and patient records, and the patient focus of the system, do not reflect a high level of integration. Integrated information infrastructure is needed to serve the needs of all stakeholders, including the patient. Additional research is required to determine how widespread these perceptions are among physicians and how these perceptions compare to those of other providers and stakeholders

involved in health reform. Moreover, we need more and better information on regional differences in physicians’ perceptions about the nature and extent of integration across Canada. References 1. The National Forum on Health (on-line) 2001. [Accessed September 9, 2002]. Retrieved from: www.parl.gc.ca/37/1/parlbus/commbus/senate/comE/SOCI-E/rep-e/repintmar01-e.htm 2. Kirby, MJL. The health of Canadians – The federal role (on-line). [Accessed September 2, 2002]. Retrieved from: www.parl.gc.ca/37/1/parlbus/commbus/senate/comE/SOCI-E/rep-e/repintmar01-e.htm 3. Romanow, R.J. Shape of the future of healthcare. Interim report (on-line) 2002. [Accessed September 9, 2002]. Retrieved from: www.healthcarecommission.ca 4. Rogers, A, Scheaff, R. Formal and informal systems of primary healthcare in an integrated system: Evidence from the United Kingdom. Healthcare Papers 2000:1(2):47-58. 5. Leggat, SG, Walsh, M. From the bottom up and other lessons learned from down under. Healthcare Papers 2000:1(2): 37-46. 6. Hernandez, SR. Horizontal and vertical healthcare integration: Lessons learned from the United States. Healthcare Papers 2000:1(2):59-65. 7. Shortell, SM, Gillies, RR, Anderson, DA, Morgan Erickson, KL, Mitchell, JB. Remaking healthcare in America. 2000: 2nd ed. San Francisco: Jossey-Bass. 8. Coddington, DC, Moore, KD, Fischer, EA. Making integrated health care work. 2nd ed. Englewood, CO: Centre for Research in Ambulatory Health Care Administration; 2000. 9. Devers, KJ, Shortell, SM, Gillies, RR, Anderson, DA, Mitchell, JB, Morgan Erickson, KL. Implementing organized delivery systems: An integration scorecard. Healthcare Management Review 1994;l9(3):7-20. 10. Lozon, J., Vernon, SE. Governance as an instrument of successful organizational integration. Hospital Quarterly 2002:6(1):68-71. 11. Stensland, J, Stinson, T. Successful physician-hospital integration in rural areas. Medical Care 2002;40(10):908917. 12. Leatt, P, Pink, GH, Guerriere, M. Towards a Canadian model of integrated healthcare. Healthcare Papers 2000;1(2):13-35. 13. Lewis, S, Kouri, D. Regionalization: Making sense of the Canadian experience. Healthcare Papers 2004;5(1):12-31. 14. Restructuring B.C.’s Health Authorities. [Accessed September 9, 2002]. Retrieved from: www.healthservices.gov.bc.ca/socsec/restruct.html 15. Alberta Health and Wellness. [Accessed September 10, 2004]. Retrieved from: http://www.health.gov.ab.ca/ 16. David Thompson Health Region Homepage. [Accessed September 10, 2004]. Retrieved from: http://www.dthr.ab.ca/about/index.htm. 17. Shortell, SM, Gillies, RR, Anderson, DA, Mitchell, JB, Morgan, KL. Creating organized delivery systems: The barriers and facilitators. Hospital and Health Services Administration 1993;38:447-466. 18. Starfield, B. Primary care: Balancing health needs, services, and technology. New York: Oxford University Press; 1998. 19. Roblin, DW, Vogt, TM, Fireman, B. Primary care health teams: Opportunities and challenges in the evaluation of service delivery innovations. Journal of Ambulatory Care Management 2002;26(1):22-35. –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Acknowledgments Alberta Heritage Foundation for Medical Research supported this project by providing funding for this study. The study could not have been completed without support from the Vancouver Island Health Authority, Calgary Health Region, David Thompson Health Region, College of Physicians and Surgeons of British Columbia. Our thanks to the College of Physicians and Surgeons of Alberta for providing access for data collection. –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

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Healthcare Management Forum Gestion des soins de santé