Integration and differentiation in hospitals

In December last year I wrote a blog about the review of my first article. In this first article I described 106 logistical parameters, which I found in international literature. In the majority of the papers I had read, the focus was on one particular parameter – resource utilization or length of stay for example – and the minority of the papers considered looking at the hospital as a whole.  In my selection of almost 300 papers I identified 95 different parts of the hospital that had been researched. Among these were the OR department, the IC patient process, the process of blood samples and so on.

This showed fragmentation of logistics in research, while at the same time many researchers claim that there should be more integration in healthcare. In our first revision we described integration as coordination and cooperation between entities that function together as a unified whole. Last week I received the response of the reviewers on this first revision. The main theme they wanted discuss was ‘integration’: what it is and in what way does it relate to logistical parameters.

Integration is a very interesting and relevant issue I think. People working in hospitals – in the projects I am involved in – often talk (and complain) about the lack of collaboration and communication between the various people and departments in hospitals. But the adverse is true as well: a lot of effort already goes into meetings to talk things through and create common ground for changes in hospitals. For example, in the design and building of a new hospital  I was involved in some years ago, we had around 150 meetings with groups of future users of the building, in a period of about 1,5 year. The contractor, who built the hospital, found this number of intense meetings (they lasted for about 2 hours each) pretty insane and would probably say too much integration effort was going on. Others would still claim they had not been involved enough in the process of designing the hospital. So the question is when integration is ‘good’ and needed and in what cases differentiation is required to be able to work effectively?

This is the central theme in the work of a paper called ‘Differentiation and Integration in Complex Organizations’ by Lawrence and Lorsch, a classical work according to my professor, published already in 1967, but new to me. I found it very interesting because this research, done in the chemical processing industry, shows that both integration and differentiation are required for organisations to perform well. In this research it is stated that an organisation consists of subsystems, that each execute a part of the overall task, in relation to the (sub)environment of the (sub)system. Integration is defined as ‘the process of achieving unity of effort among the various subsystems in the accomplishment of the organization’s task.’ So subsystems have their own tasks and relate to their own environment – say  for example the Purchasing department relates to hospital’s suppliers and the Board of Directors relates to the local or national authorities – and they would need to be unified to to achieve overall effective performance of the system.

The next step is to describe, based on the case study research I have done, what are the subsystems in a hospital, how they collaborate, integrate or not and whether this is (seen as) effective.


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