Integrating VA Medical Centers

VanDeusen Lukas, Mittman BS, Hernandez J, Macdonald J, Yano E, Simon B. Integrating VA Medical Centers. Paper presented at: VA HSR&D National Meeting; 1999 Feb 24; Washington, DC.

Objectives: There is a strong trend in the VHA, as in the private sector, to integrate healthcare facilities. This multi-year study was designed to analyze 14 VHA integrated systems in order to develop management lessons for other VHA systems. Drawing from the first phase of the study, this paper examines: 1) the effects of facility characteristics on integration structures; 2) the planning and change processes used by the integrating systems; and 3) the perceived impact of integration on operations, patient care and staff morale in different integration settings.Methods: Qualitative and quantitative data for 14 integrating systems were drawn from four sources: 1) face-to-face interviews with top leadership, middle managers, and representative staff and clinicians; 2) a survey of all system department heads and service chiefs (91% response rate); 3) documents provided by the systems and 4) VA administrative and research databases. Descriptive analyses identified patterns in characteristics, processes and structures of integrating systems. Systems were clustered by patterns and compared to assess differences in effectiveness on selected variables. Results: 1) Systems with one clearly dominant partner - an affiliated tertiary facility paired with a smaller community or specialty facility -- were more likely than systems with equal partners to be structurally integrated two years after integration approval - particularly in clinical departments - and to have consolidated acute care services to one campus. Equal-partner systems - with facilities similar in size, complexity and academic affiliation -- were less likely consolidate services to one campus and/or combine departments across campuses. Equal-partner systems on average reported lower impacts of integration on department operations and lower perceived staff moral. 2) Systems differed in the speed of appointment of new managers and in the roles management and staff played in the early planning processes. Systems that appointed the director immediately and used a model of shared leadership were more effective in terms of a shorter integration process, higher staff satisfaction with the p rocess and higher perceived staff morale. Conclusions: 1) The characteristics of the participating facilities strongly influence the structure of the integrated system. Equal-partner systems tend to take longer and/or result in less complete clinical integration. Integration among equal partners is often more difficult than in dominant partner systems because more issues have to be negotiated extensively. 2) Effective planning processes balance strong leadership with early involvement of middle managers. Staff are most satisfied when they have an opportunity to participate within a clear structure - after key decisions are made about the organizational structure, and when they are given clear guidelines for planning. 3) Clinical integration is a key aspect of VHA integrations. In most of the systems studied, the majority of clinical services are integrated. These patterns are consistent with VHA goals of creating integrated delivery systems, not simply joining hospitals for administrative purposes.Impact: The first phase report has been distributed to all VISNs and medical centers to inform their efforts in integrating services and facilities, and more broadly creating integrated delivery systems. Study investigators have presented their findings in VHA systems beginning the integration process