Organizing for sustainable inter-organizational collaboration in health care processes

ABSTRACT

Integrating health care services has proven to be important from both the patient and organizational perspectives. This study explores what defines a perceived well-functioning collaboration in the inter-organizational process of providing assistive devices in Sweden. Two focus groups comprising participants with profound knowledge of collaboration were performed, and data were analyzed in five steps, resulting in a data structure. Results yield the identification of three interacting processes: coordinating efforts to patient needs, ensuring evidence-based practice, and planning for efficient use of resources. These processes affected one another, and, therefore, would likely not have been effectively managed separately. The study contributes to theories of process management and organization by specifically focusing on how to analyze and improve sustainable collaboration in health care processes at both the management and professional levels. Theoretical frameworks that show different ways of organizing collaboration, as well as the concepts of action nets and boundary objects, can support both analysis and planning of collaboration. The intention would be to develop integration in inter-organizational health care processes, resulting in more person-centered care.

KEYWORDS:

• Focus groups
• interprofessional collaboration
• integration
• partnership
• health and social care

Introduction

Due to highly driven specialization, health care services often involve multiple organizations. Specialization provides opportunities for efficiency but can also cause difficulties related to lack of coordination. The concept of integration, introduced by Lawrence and Lorsch (1967), describes how this challenge can be met and the type of collaboration required to achieve unified efforts in an organization to meet environmental demands. Achieving integration within one organization is demanding. Integrating activities of multiple organizations might be even more difficult. As an answer to these challenges, person-centered care has been introduced.

Person-centered care is an approach where the professionals confirm the experiences and interpretation of illness that their patients depict. The approach is based on mutual respect and understanding, and the promotion of patients’ right to self-determination (McCormack, Dewing, & McCance, 2011). To achieve integration and effectiveness, collaboration among professionals and organizations is essential. Critical factors for well-functioning collaboration have been described by several researchers; see for instance D’Amour, Ferrada-Videla, San Martin-Rodriguez, and Beaulieu (2005), Lemetti, Stolt, Rickard, and Suhonen (2015) and Suter et al. (2009). But health care professionals seldom manage to create all necessary conditions to support successful collaboration on their own. There is, therefore, a need for research on collaborative practice (Lyngsø, Godtfredsen, & Frølich, 2016; San Martín-Rodríguez, Beaulieu, D’Amour, & Ferrada-Videla, 2005) and better understanding of collaboration as an instrument for integration.

To achieve efficiency from patient, organizational, and inter-organizational points of view, use of integrated resources is a prerequisite. Bell, Kaats, and Opheij (2013) point out that there are few examples of how leaders can create well-functioning inter-organizational collaboration. They argue that research has largely focused on individual aspects of collaboration without considering practical application. In addition, management should discuss the purpose of the collaboration and take into account the contextual factors that can facilitate collaboration (Mandell & Steelman, 2003).

When several organizations are involved in health care, boundaries are set by policies, laws, rules, and budgets, but also by differences in culture (Dunér & Wolmesjö, 2015). As a way of overcoming boundaries, process management has become a methodology for creating horizontal management structures aimed at facilitating value flows within and between organizations. However, combining vertically oriented hierarchical management and horizontal process management in health care is difficult. It is not entirely evident that the two perspectives easily can coexist when structures and principles are built on a functional view of the organization (Hellström, Lifvergren, & Quist, 2010). These circumstances can affect efforts to establish collaboration regarding common resources and management structure. In addition, integration efforts are often organized as projects, hindering communication about experiences of collaboration and thereby causing delays in learning (Löfström 2010).

In summary, research on integrating health care services through collaboration between organizations and professionals is of great interest today, but several authors indicate a need for further studies of practices, especially on system and organizational levels, for understanding what creates sustainable collaboration. As a contribution to both research and practice, this study aims to explore what defines a perceived well-functioning collaboration in the inter-organizational process of providing assistive devices.

Methods for analyzing relationships in organizations and processes

To investigate relationships within and between organizations, and thereby to contribute to the development of collaboration, there are many different methods. Horizontal and vertical integration can be described and analyzed through the concepts of coordination, cooperation, contracting, and collaboration (Axelsson & Axelsson, 2006). Functional integration (for example, via shared policies) and normative integration (for example, via common goals) both describe connections between different levels of a system (Valentijn, Schepman, Opheij, & Bruijnzeels, 2013). Processes of trust and control are, therefore, important for bridging gaps in integration efforts at professional, organizational, and system levels (Valentijn et al., 2015).

Furthermore, care is sometimes described as a single flow of sequential activities, but more often several functions and actors are involved simultaneously and work in parallel in the caring for the patient. The concept of action nets (Czarniawska, 2004) can, therefore, be used when analyzing connections between actors in and between processes. An action net describes a pattern of actions performed by actors with different functions in a specific context. The action net changes depending on which actions are being performed. Actors are exchangeable, as they act based on their assigned roles in the action net. In contrast, a network consists of specific individuals, and any change of actors may alter the network. Action nets often involve different organizations, sometimes based on formal agreements, but are not coupled with places, issues, or people (Czarniawska, 2004).

When analyzing relationships in processes and organizations, boundaries are important. A better understanding of how relationships develop might be achieved by studying how actors perceive objects (Sullivan & Williams, 2012). The concept of boundary objects can be used for understanding how coordination and collaboration across boundaries is facilitated (Star & Griesemer, 1989). A boundary object can be seen as a bridge over boundaries, unifying different viewpoints. Depending on the context, boundary objects can take different forms. Star (2010) finds the concept to be most useful for a specific scope and at the organizational level. Boundary objects can also serve as stabilizers in action nets; patients can function as boundary objects, providing shared meaning for actors in the chain of care (Lindberg & Czarniawska, 2006). From an action net perspective, when an object is used, it becomes part of the process and, sometimes, a boundary object (Lindberg & Walter, 2013).

Background

A patient’s need for help in functioning in his/her environment is met by different actors prescribing, adapting, supplying, and repairing assistive devices as part of care, habilitation, and rehabilitation. Assistive devices, such as wheelchairs and walkers, aim to compensate, improve, or maintain function and ability and prevent future loss of function and ability for disabled persons, as stated in the International Classification of Functioning, Disability and Health (ICF) (World Health Organization, 2001). This study is performed in Sweden where prescribing assistive devices has switched from a technology-centered approach to a user-centered approach, and access to appropriate assistive devices is regulated in the Swedish Health and Medical Services Act (Svensk författningssamling, 2017). Scherer and Craddock (2002) state the importance of matching person and technology for patients to overcome barriers and achieve their goals.

The study is performed in Norrbotten, which is the northernmost county in Sweden, covering about a quarter of Sweden’s land area but only 2.5 percent of the inhabitants. Norrbotten County has about 250,000 inhabitants in 14 municipalities, with about 2,800 to 78,000 inhabitants.

Municipalities and county councils in Sweden are self-governing authorities but with different responsibilities, mostly regulated through legislation. County councils are responsible for public health and ensuring that everyone has equal access to health care services. Since 1992, municipalities have been, among other things, responsible for the care of the elderly and persons with disabilities, including the provision of health and social care in special accommodations and the person’s home. In 2013, municipalities in Norrbotten County took over responsibility for all home care, excluding physicians. The county council administers the supply of assistive devices, but the county council and the municipalities are jointly responsible for financing assistive devices. In 2017, the costs totaled about SEK 91 million, of which the municipalities accounted for approximately 70 percent.

As Swedish legislation does not support advanced collaboration between public organizations, the county council and all 14 municipalities in the county have, since 2006, a joint agreement on how to collaborate in providing assistive devices. The management considers the agreement to be important for collaboration across organizational borders, which has resulted in three revisions, and different types of inter-organizational meetings have evolved. Financial transactions related to the supply of assistive devices were built on jointly agreed financial principles based on intentions to reuse assistive devices. Additionally, the organizations collaborate on common guidelines for prescribing assistive devices. These guidelines were decided by political assemblies in the county council and municipalities and based on the ICF (World Health Organization, 2001).

In conclusion, the development of collaboration in the process of providing assistive devices in Norrbotten aroused the interest of the authors in understanding why the collaboration was considered successful by the management and actors in the process.

Methods

A qualitative approach was decided upon in order to capture participants’ experiences and views of collaboration in providing assistive devices. Therefore, a focus group study was performed. Because several organizations and professions were involved, focus group discussions with multiple actors at the same time enhanced the chances of getting insight into events encountered in practice. Focus group discussions were chosen to obtain information from each participant as well as create a dynamic interaction between participants to generate rich data in a short period; see also Morgan (1996).

Participants

A total of 12 individuals were invited and agreed to participate in one of two focus groups. The main invitation criterion was long experience of working with assistive devices. The selection of participants was intended to include persons with profound and extensive experience of collaboration. The participants were suggested by two consultants with extensive knowledge in the area. Two late cancellations from one group were received. One cancellation was due to personal reasons, while the other was due to the work situation. Of the remaining 10 participants, four were employed by a municipality, and six were employed by the county council. Four participants worked as consultants, where one of their duties was to support prescribers of assistive devices for patients. All participants had extensive experience in working with assistive devices, varying from 10 to 40 years. Six participants had degrees as occupational therapists, three as physiotherapists, and one as a technician. All participants received oral and written information about the study and signed a written consent to participate in the focus group discussion.

Data collection

Data collection entailed two focus group discussions in the autumn of 2015. The first author conducted the focus group discussions, and the last author supported with notes and questions. The first and the last author produced official documents about assistive devices about seven years ago, sometimes together with a couple of the participants. When the focus group study was performed there were no ongoing professional relationships with these participants.

Focus group discussions took place in two parts of the county. The first group included six participants, and the second group included four participants. The focus group discussions lasted approximately 70 minutes and were audio-recorded and transcribed verbatim. The discussions were initiated with the question, ‘Would you please describe your view of collaboration in providing assistive devices and which factors you think may affect collaboration?’ To have a common starting point for the focus group discussions, participants received an image showing the process of providing assistive devices. The process is described in a document from the National Board of Health and Welfare (Socialstyrelsen, 2017) and aims to help people who prescribe assistive devices.

The focus group discussions were conducted with an interview guide covering three areas important for understanding collaboration on different levels (individual, organizational, and societal). Before ending the discussions, the moderators checked that all three areas had been covered and added a few complementary questions.

Data analysis

The analysis consisted of steps inspired by the grounded theory articulated by Gioia, Corley, and Hamilton (2013). To enable close resemblance between data and coding, preconceived categories or codes were not used. Code labels were intended to reflect ongoing action and processes (Charmaz, 2014).

A preliminary analysis followed directly after the first focus group with the aim of guiding the next focus group discussion. The analysis started by reading the verbatim transcripts to acquire an overall sense of the content. After the second focus group discussion, the procedure was repeated. The intention was not to compare the groups but to get a comprehensive picture of collaboration.

The statements were read to find similarities and differences in data to distinguish codes. The second step in coding was intended to reduce the number of codes. It resulted in 16 first-order categories named with participants’ terms and with words helping to detect ongoing processes. The third step was intended to revise, refine, and assemble the categories in an iterative process. The analysis resulted in five themes with six subthemes. The fourth step was intended to organize the themes in aggregated dimensions, which enabled the development of three dimensions. Themes, subthemes, and dimensions were all named with words highlighting the processes. The final data structure is illustrated in Figure 1. The fifth step was intended to examine connections within and between dimensions. The identified connections are shown in Figure 2.

Figure 1. Data structure.

Figure 2. Connections in the process of providing assistive devices.

To ensure data trustworthiness, the authors repeatedly discussed codes and categorizations. The first author made the initial coding and, in several meetings with all authors, the coding was discussed in relation to original data and gradually improved until consensus was reached. All authors had previous acquaintance with qualitative analysis. Two of the authors were well versed in personal-centered care and health care processes, and the other two were well acquainted with organization theory.

To ensure the interpretation of data, participants were invited to a meeting in the spring of 2016 where the findings were presented and discussed. Four participants took part in the meeting and one gave comments by phone. Before the meeting, the participants received a draft of the analysis.

Ethical considerations

The participants were provided written and verbal information about the study. They were also informed that their participation was voluntary. Oral and written informed consent was obtained from the participants. According to Swedish law (Act 2003:460) concerning Ethical Review of Research Involving Humans (Svensk författningssamling, 2003), ethical approval by an external authority is not required when no sensitive personal data are collected. All data were treated as confidential and the General Data Protection Regulation (Datainspektionen, 2016) has been applied for the protection of the personal data.

Results

From the analysis, three interacting processes emerged: (1) coordinating efforts to patient needs, (2) ensuring evidence-based practice, and (3) planning for efficient use of resources. Collaboration at various levels was considered a requirement to meet patient needs while maintaining efficient use of resources such as assistive devices and personnel.

Results are presented based on three identified processes (see Figure 1). Participants’ statements received considerable attention to connect the data structure and focus group discussions. Identified process connections are illustrated in Figure 2.

Coordinating efforts to patient needs

The analysis showed that, depending on patients’ need for care and/or rehabilitation, the activities of providing assistive devices were carried out by several actors. Patients with complex needs often required different assistive devices of varying complexity. When complexity increased, higher demands were put on the equipment, its maintenance, and expertise for adaptation. Patient needs also determined the number of actors involved in care and rehabilitation, which affected demands on interprofessional collaboration and coordination of efforts. Collaboration was described as informal contacts between actors according to the patient’s specific needs.

During the focus group discussions, the participants emphasized a number of subjects they considered important. They discussed how their working days were affected by collaboration, which is described in the themes of maintaining partnership and establishing an effective process.

The theme, maintaining partnership, describes how efforts of providing assistive devices to people with disabilities were perceived as both satisfying and stressful for the actors involved. The participants repeatedly expressed that there was benevolence and a clear patient focus among actors. To facilitate contacts, each actor created a network with actors being involved in work depending on the specific patient. Two subthemes crystallized as follows.

The subtheme, taking personal responsibility, describes participant views of responsibility and commitment as a success factor for collaboration. The first-order category, doing everything to make it work, indicates the importance of having confidence in each other and trusting that there is no hidden agenda. Participants mentioned personal commitment as being crucial and that the patient may suffer if an actor fails to take responsibility. As one participant said,

then usually someone ends up waiting. (Focus group 1)

The subtheme, establishing a network, reflects participant commitment in creating value for patients through interprofessional collaboration with other actors. The first-order category, being a part of the chain of care, includes examples of situations when patients’ well-being was the focus of collaboration with actors in health centers, hospitals, and municipalities.

While participants brought up the issue of whether patients were aware of which organization actors came from, they noted that this aspect was probably not perceived as important by patients. Getting feedback on patients’ thoughts about whether activities undertaken contributed to a better everyday life was perceived as important by the participants; however, they could not recall any joint patient surveys. The change in responsibility for home care was perceived as positive for patients and an improvement seen from a community perspective. As one person said,

It is actually like a success factor that we have been able to work with the patients in their home. … I do not think they got so much help in their home before. … Prescriptions for assistive devices must have increased … it is a growing market, you are there [in the home of the patient] and meet their needs. (Focus group 1)

The participants stated that providing assistive devices includes several functions, professions, and actors with different competencies. Actors often had non-replaceable skills, which entailed strong interdependencies within the network; participants explained that respect for each other’s competencies was crucial. Personal knowledge of actors was considered important and shown in the first-order category, knowing what the others can do.

Participants mentioned the work becoming cumbersome if an actor was unable to acquire knowledge about the other actors involved. Established networks were mentioned as a way to facilitate the introduction of new employees. Another way mentioned to gain knowledge of other actors was practical competency development.

Why not participate in the daily activities at the hospital? … And it was the best collaboration you could get. … My collaboration with the physiotherapists works much better. (Focus group 2)

The theme, establishing an effective process, reflects the participants’ discussions regarding the importance of meeting patient needs safely and efficiently. Two subthemes illustrate what participants considered as defining an effective process.

The subtheme, establishing defined roles, shows different roles and functions in the process. The participants described the importance of everyone knowing his or her responsibilities, important for simplifying a transition when someone else takes over the tasks. This is shown in the first-order category, knowing their role in the process.

The participants indicated a need for support resources able to act as links between different processes. Support resources were also requested for selecting suitable assistive devices for a patient with special needs. The need for supporting resources was pronounced in workplaces with fewer employees or when actors were new in their roles. Statements such as the following illustrated the first-order category, obtaining necessary support.

Sometimes we forget that you [consultants] are accessible. You go on working in solitude until you remember, oh right, one can get in touch. (Focus group 2)

The subtheme, establishing functioning routines, illustrates that the process of providing assistive devices consists of various activities, documented in routines and checklists. In the first-order category, agreeing on relevant routines, participants pointed out that providing an assistive device should be based on the patient’s individual needs. Therefore, it was perceived as important that there be routines for handling various situations and to ensure that the devices were distributed in time. Sometimes the desire to solve problems resulted in rules being circumvented. As a participant said,

When it fails, one has to solve it as well as possible. (Focus group 1)

In the focus group discussions, it emerged that special expertise was needed to coordinate activities for the patient, including maintenance and transportation of assistive devices. One issue mentioned was the information exchange among health care providers. This key role of coordination is held by the person who prescribes assistive devices and is described in the first-order category, coordinating the process.

You must have many tentacles, many threads to pull. (Focus group 2)

The participants pointed out that the assistive devices often were essential to enable patients to leave the hospital and receive care in their home. If the process worked poorly from a patient’s perspective, typically the procedures for handover were not optimal. Time was considered important, both for the patient and his/her family and for the actors involved. Planning was highlighted as a key activity and illustrated by one participant:

That you can come in and meet with all affected persons … time is important today. … There are a lot of people involved. (Focus group 1)

Ensuring evidence-based practice

The participants shared experiences of patients of all ages, with different physical or mental disabilities, both temporary and permanent, and with a need for assistive devices to cope with their everyday lives. The patients had varying conditions with which they had to deal, either on their own or with support at home. Many patients were older people requiring special accommodations. The participants pointed out that when several organizations are involved a question of equal terms becomes important. They agreed that there was a need for collaboration between organizations regarding how these terms could be put into action. This is summarized in the theme, creating equal terms between patients, and illustrates the importance of having a framework that is agreed upon for prescribing assistive devices. This was considered especially important, as the chain of care consists of multiple organizations in the course of events in the patient’s life.

To prevent a patient from being affected by boundaries between organizations, common guidelines for prescribing assistive devices have been developed. The participants considered these guidelines important for interprofessional collaboration and smooth operations between actors, the patient included. The first-order category, achieving equal conditions, shows that the main purpose of the guidelines is to ensure that patients receive the same terms and conditions regardless of where they live in the county and where they receive care. The participants mentioned that mutual agreement regarding the guidelines required significant efforts from all parties involved, and examples of difficulties were described.

The first-order category, facilitating prescriptions, reflects how participants perceived guidelines as a support to the prescriber when selecting assistive devices. The prescriber’s responsibilities are summarized below:

Minding what you are allowed to prescribe and how it should be done, … thinking about the safety of the patient … and that it does not bring unnecessary costs for the society or lead to delays in preventing the patient from arriving home on time. (Focus group 1)

As access to assistive devices was considered essential to patients’ everyday life and often a prerequisite for care in a patient’s home, examples of how single events as well as long-term changes in society influenced the process and its effectiveness are shown in the first-order category, responding to new patient needs. The participants noted that new and complex needs call for more efforts from rehabilitation and nursing professionals, while the number of actors surrounding a patient increase. The participants’ dialogue about how shorter treatment times at hospitals affected the process is shown in the following quote:

Patients get home earlier nowadays. More assistive devices are needed in the acute phase, and it has to go fast. (Focus group 2)

Planning for efficient use of resources

The importance of actors having access to adequate resources, such as available and functional assistive devices, was pronounced. Participants gave examples of how common resources were beneficial to both the organization (costs) and the patient (quality and time). The participants mentioned dilemmas they had experienced. These are summarized in two themes, providing stable conditions and supplying adequate assistive devices.

The theme, providing stable conditions, illustrates how different conditions in the participants’ everyday work affected their ability to achieve a satisfying result. Examples are summarized in the first-order category, being able to plan the workday. Statements showed how planning was affected by events in the environment, often due to the different organizations involved. One example mentioned was in regard to a patient leaving the hospital.

We cannot offer enough assistive devices. We cannot offer the ergonomic assortment that the workforce needs. We cannot offer support when they [patients] come home so that everyone gets to know what has happened and why the patient was hospitalized. (Focus group 2)

Another aspect documented in the first-order category, gaining management support, demonstrates the need for support from both line managers and politicians who can influence societal conditions. The participants had large networks within the organization, with other actors in the county, and within their profession. To maintain these networks and develop their skills, participants mentioned a need for opportunities to organize meetings and participate in appropriate education; however, lack of time and the organization’s economic conditions influenced these requests.

It will cost money, so it is not encouraged. (Focus group 2)

The theme, supplying adequate assistive devices, shows that the participants thought collaboration needs to be formalized regarding the supply of assistive devices to avoid problems for actors; this is summarized in two subthemes.

The subtheme, taking shared responsibility, reflects the importance of collaboration from an organizational perspective. The first-order category, being equal partners, shows the participants’ thoughts about the importance of conducting all collaboration on equal terms between parties. One issue was whether organizations were jointly responsible, or one organization dominated over the others. The recent home care reform had transformed relations between involved parties, but it was perceived as difficult to change ingrained patterns. Another aspect was that using the customer concept between actors could build barriers.

Due to the plenitude of organizations, it is important to be equal. You may not use the customer concept too much. … We are partners. (Focus group 1)

Problems arising from the unclear division of responsibilities were mentioned, particularly related to the transfer of responsibility for home care. Collaboration when purchasing assistive devices was another issue that engaged the participants.

The importance of communication was addressed in the first-order category, creating forms of dialogue and feedback. In a process with many parties, participants highlighted the importance of having opportunities for dialogue and feedback. One aspect was how to deal with emerging problems through deviation management.

I’m quite happy that they [walkers] are removed, but it led to a feeling of nothing happening even if we provide feedback. The problems with them were obvious. (Focus group 2)

The subtheme, developing common rules, illustrates problems that arise due to several organizations being involved. The participants found it essential that rules be documented and decided in a formal way. The first-order category, agreeing on and documenting the rules, reflects the participants’ agreement about the importance of avoiding discussions between actors, for example, about payment flows. They pointed out the need for ‘control by rules,’ as one participant said.

The first-order category, creating flexible rules, reflects the focus group discussion as to whether rules were flexible over time and if they could work if conditions changed. As one participant summarized,

It requires flexibility. It is probably impossible to write an agreement that is foolproof. (Focus group 1)

One problem raised was long-lasting contracts in the purchase of assistive devices and that perceived quality deficiencies could not be corrected during the contract period.

Analysis of collaboration in the process of providing assistive devices

The analysis reflects how focus group participants viewed collaboration in the three processes: coordinating efforts for patient needs, ensuring evidence-based practice, and planning for efficient use of resources. An illustration of the connections between the identified processes is presented in Figure 2.

To better understand why collaboration when providing assistive devices was perceived to work so well, the concept of boundary objects was used to examine the coordination of collaboration. When analyzing connections between the processes, four boundary objects were found: (a) a patient in need of assistive devices, (b) the guidelines for prescribing assistive devices, (c) the financial principles, and (d) the joint agreement that connects the entire process model. The patient’s role as a unifying link between professionals was apparent both in the focus group discussions and in the joint agreement. The joint agreement could also be viewed as a catalyst for developing collaboration between the involved organizations.

The analysis shows that an assistive device may function as an object with specific purposes in different parts of the process and by different actors. From a prescriber’s perspective, the function of an assistive device is of interest. A technician may view the device from a more instrumental perspective. Viewed from a management perspective, an assistive device has a financial value, and for a politician, its usage may represent a tool for improving welfare in a community. An assistive device becomes a boundary object in relation to a patient. There were also boundary procedures present, such as written routines, information, and education activities. In addition, tacit knowledge was described to be largely present.

The participants described interprofessional collaboration taking place in both action nets and established networks within and between the processes. Some action nets arose when problems emerged, for example, failures of deliveries, at hospital discharge, or in temporary activities such as purchasing assistive devices or developing the common guidelines. It was obvious that the handovers between actors were crucial, for example in situations when the actors involved were changed. It emerged that the process ensured stability in the relations between actors; for example, the home care reform appeared seamless as seen from a patient perspective.

The analysis shows a consensus among participants that collaboration functioned well as a whole and collaboration at both management and interprofessional levels had progressed over the last decade. Learning from collaboration was shown by the repeated evaluation of the joint agreement. The relationship of forces was a factor that influenced collaboration between actors and relations between the organizations, for example the use of the customer concept and the historical background.

Discussion

This study aimed to explore what defines a perceived well-functioning collaboration in the inter-organizational process of providing assistive devices. The analysis shows that sustainable collaboration is dependent on implementation of administrative and management arrangements supporting relationships between professionals, professions, organizations, and processes.

Both the focus group discussions and the extended duration of the joint agreement indicate that involved actors and management considered the process and collaboration to be well-functioning. However, the participants pointed out several problems that had to be managed: the meaning of collaboration would need to be clarified by management, questions would have to be raised to other decision levels, and flexibility would be required as part of the process. The study shows, therefore, the need to persist in sustaining and improving the collaboration.

To analyze and develop collaboration, both theory and empirical data are indispensable (D’Amour et al., 2005). Therefore, theoretical frameworks inspired the analysis of collaboration in the study (Axelsson & Axelsson, 2006; Valentijn et al., 2013). Cooperation (vertical integration) between involved organizations was based on the joint agreement. Interprofessional collaboration (horizontal integration) mainly took place between actors when they worked with patients and in various action nets and networks. Functional integration was promoted by a joint agreement, financial principles, and common guidelines. Normative integration was strived for through shared values and common goals in the joint agreement, combined with benevolence and a wish to give patients their best effort. The concepts of action nets and boundary objects (Czarniawska, 2004; Lindberg & Czarniawska, 2006; Lindberg & Walter, 2013; Star, 2010; Star & Griesemer, 1989) were used to describe connectivity and stability in a coherent process model (Figure 2).

The analysis shows that the prescriber had an important role as coordinator of all actors involved. Because members of the team varied depending on patients’ needs, the coordinator needed to have knowledge of many actors and to ensure the patient’s active participation. Here, both leadership skills and the ability to summon necessary resources were crucial. Good relationships among professionals are important for integration (Lemetti et al., 2015; Lyngsø et al., 2016; Suter et al., 2009), but participants in this study pointed out that this was not enough, and collaboration would be formalized when different organizations were involved (San Martín-Rodríguez et al., 2005).

The participants also mentioned that power relations affect collaboration, but in contrast to Dunér and Wolmesjö (2015), they pointed out organizational relationships, such as use of the customer concept, rather than interprofessional power relationships (D’Amour et al., 2005). Furthermore, value creation for the patient is best carried out when all parties act as equal partners (Karlsson, Garvare, Zingmark, & Nordström, 2016). Consequently, long-term efforts to build trust between parties, both management and actors, are crucial for bridging gaps between different stakeholders’ perspectives on collaboration (Valentijn et al., 2015).

Improvement in single processes, often called chains of care, is common in health care. This study shows that single process improvement is not sufficient to ensure efficiency from both the patient and organizational perspectives. Single processes affect one another and, therefore, cannot be effectively managed separately (Ackoff, 1971; San Martín-Rodríguez et al., 2005). Analysis showed the importance of a coherent system for managing patient processes that cross organizational boundaries, and that the connections between processes need to be clear. For instance, participants perceived the supply of assistive devices as critical because the devices represented a substantial economic value. Supply chain management efficiency is crucial in health care (Fibuch & Ahmed, 2015), especially when multiple organizations are involved.

For sustainable integration, inter-organizational collaboration in projects can be counterproductive, and there is a need for future research on different forms of organizing vertical integration (Löfström, 2010). The results from the study confirm this. Even if implementing process management is difficult in health care organizations (Hellström et al., 2010), processes could act as frameworks for management control in inter-organizational environments where hierarchical structures are weak. In this way, both vertical and horizontal integration could be achieved in integration efforts, as well as relational trust and functional control (Axelsson & Axelsson, 2006; Valentijn et al., 2015, 2013).

In summary, the study indicates that focusing on organizational hierarchies could preserve boundaries between and within organizations and, therefore, impede learning among actors in health care processes. A consequence might be that pursuing a culture that assumes the patient’s perspective is hampered (McCormack et al., 2011). Learning about experiences of collaboration is, therefore, essential for both management and research (Bell et al., 2013; Lemetti et al., 2015).

Limitations

The choice of using focus groups for data collection was based on the premises of gaining access to participants’ views collectively with a low degree of researcher control. A limitation is that group pressure could mean that certain topics were not addressed. The small number of participants is another limitation. The conscious choice to recruit participants with extensive experience from collaboration and the moderators’ in-depth knowledge of related written documents strengthen the results and lessen the limitations. To strengthen the trustworthiness of the results, situational factors, especially participant characteristics and the moderators’ role, should be analyzed (Orvik, Larun, Berland, & Ringsberg, 2013). These factors, as well as the organizational context, have been considered during data analysis.

The method was strengthened by the collection of rich data on collaboration in the studied process provided by the focus group discussions and including a meeting for participant validation. Barbour (2005) states that inviting those involved to a dissemination session may be practical for both presenting findings and obtaining responses from participants.

The first and last author’s previous work with official documents about assistive devices, sometimes together with some of the participants, may have been both an advantage and a disadvantage when conducting focus group discussions and interpreting data. To reduce the moderator’s effect on the focus group discussion, the same question and the same image of the process was used, as well as a low involvement of the moderators during the focus group discussion. To prevent problems and increase the trustworthiness of the analysis, all authors discussed both interpretations and conclusions on several occasions.

Concluding comments

This study has explored the evolution of collaboration in an inter-organizational health care environment to achieve integration of care, habilitation, and rehabilitation with a patient perspective in focus regarding the provision of assistive devices. A better understanding of how administrative and management arrangements can support relationships between professionals, professions, organizations, and single processes is needed. The findings could be a starting point for analyzing and developing collaboration in inter-organizational health care processes, such as providing assistive devices, as well as other health care processes where several organizations are involved.

Analyzing action nets and boundary objects within and between organizations and processes might develop both research and practice on health care processes at a system level, with the purpose of contributing to sustainable collaboration in both intra-organizational and inter-organizational contexts. Discussions related to processes and how to collaborate are common in several areas, but as Mandell and Steelman (2003) indicate, contextual factors should be considered when determining which inter-organizational arrangements to implement. However, it is likely that the concepts of action nets and boundary objects as well as different frameworks describing collaboration can work in other contexts to assist collaboration within and between organizations and processes.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Acknowledgments

We would like to thank the participants of the focus groups.

Additional information

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Notes on contributors

Margareta Karlsson

Margareta Karlsson is a PhD. student at Quality Management at the Department of Business Administration, Technology and Social Sciences at Luleå University of Technology, Sweden.;

Rickard Garvare

Rickard Garvare PhD, is a Professor of Quality Management and Head of the Division of Business Administration and Industrial Engineering at Luleå University of Technology, Sweden.

Karin Zingmark

Karin Zingmark PhD, is a Professor of Nursing at Luleå University of Technology, Sweden and the Department of Research and Development at Norrbotten County Council, Sweden.

Birgitta Nordström

Birgitta Nordström has a PhD in Physiotherapy with a focus on rehabilitation and qualitative studies. She is working at Norrbotten County Council, Sweden and is affiliated to Luleå University of Technology.