Decision-making strategies in integrated care service networks: A collaborative multiple case study approach

Introduction:

An increased number of health and/or social care organisations seek for collaboration in organisational models like a network or local collaboration. Yet, stakeholders involved in integrated care service networks often face difficulties in their collaboration due to dilemmas around e.g. decision-making. We sought for insights into essential ingredients for decision-making and how stakeholders address decision-making dilemmas.

Theory/Methods:

Networks often face the complexity of renewal of governance processes. Governance of integrated care networks consists of other dynamics than single organisations. Decision-making is an important ingredient of effective integrated care governance. Therefore, three (1 Spanish and 2 Dutch) integrated care service networks were studied using a multiple case study approach. Data were collected via semi-structured interviews (n=23), meeting observations (n=5), focus group discussion (n=1) and analysis of documents related to project documentation (n=23). Case study findings were collaboratively interpreted by two researchers, one care consultant and one network coordinator during a focus group discussion. Practical recommendations were formulated during this session.  

Results:

The Spanish network and two Dutch networks consisted of directors, managers, professionals and/or a coordinator from respectively 3, 36 and 14 care organisations. These stakeholders employed different strategies in dealing with decision-making dilemmas. Some of the strategies focussed more on inclusiveness by involving high numbers of stakeholders whereas others strived for efficiency. Inclusive decision-making strategies included 1) inclusive structures like including at least the majority in decisions, 2) coherence between stakeholders, 3) connections between subgroups. Efficient decision-making strategies concerned 1) efficient structures like only including directly involved stakeholders in decisions, 2) stable group composition, 3) creation of subgroups. These strategies were used interchangeably due to the need for finding a balance between inclusive and efficient decision-making. To find this balance, facilitative coordination and reflective environments were suggested as potential ways during the interpretation session.

Discussions:

Our findings highlight the importance of workable decision-making strategies -as part of integrated care governance- that fit the context in which the network is embedded. Facilitative coordinators may help in this search by being involved in all subgroups of a network and by having a deep understanding of dynamics between stakeholders. Workable decision-making strategies may also be found through evaluating and learning about what drives decision-making behaviour (i.e. reflective environment).

Conclusions:

The search for enhancing the governance and decision-making in integrated care service networks requires a careful consideration of who to include in what, how to align and connect all network stakeholders, while still being able to reach (timely) decisions.

Lessons learned:

Establishing facilitative coordination and reflective environments may provide opportunities to further develop network governance and decision-making processes.  

Limitations:

In the two Dutch cases, a retrospective approach was employed which relies on the memories of respondents. Data collection occurred at a selected number of subgroups whereas data in all types of subgroups can give more profound insights.

Suggestions for future research:

Different forms of facilitative coordination and reflective environments can be compared to gain a deeper understanding about their role in governance and decision-making processes.