Establishing and sustaining collaboration across organizational boundaries within healthcare.

There have been numerous initiatives for a long period of time to enhance integration in healthcare in many countries, but these processes still prove to be challenging. More research is needed to understand the interplay between different factors and different collaboration contexts, and this paper makes a contribution in this respect. We explore how collaboration can be established and sustained across organizational boundaries. Theory and methods: We draw on the concept of sense-making (Weick) as we investigate the complex interplay between structure and agency in facilitating or constraining collaboration across organizational boundaries. The empirical material consists of 35 interviews with health personnel participating in three different collaboration initiatives between primary and secondary care regarding obesity and diabetes in Norway. The health care providers involved are all public. The aim of the collaboration is to enhance knowledge sharing and to improve prevention and treatment across primary and secondary care providers tailored to the needs of the patient. The study is part of The Research Council of Norway's evaluation program of The Coordination Reform, a reform addressing coordination and collaboration in healthcare. Results: We find that structure, competence, equality and commitment are important elements to establish and sustain collaboration across organizational boundaries. Discussion: Organizational, technological and financial structures can both facilitate and constrain collaboration. When participants determine their scope of action, they do so by interpreting the latitude provided by structural frames, but also by how they interpret the interaction with others. When participants in primary and secondary care each interpret each other as competent professionals, this enhances collaboration. Furthermore, when participants in both organizations experience the relationship between them as equal, this also enhances collaboration. Likewise, if one part interprets the other part as regarding them as less competent or superior in the relationship, this represents a barrier for collaboration. Many collaboration initiatives have one or several dedicated persons who are highly committed to the collaboration and who drive the work forward in spite of many challenges. However, if not other participants in the collaboration initiatives, as well as in their local community, interpret the collaboration as meaningful and commit themselves to the work, this represents a barrier for collaboration over time. Conclusions: Collaboration depends on participants finding collaboration meaningful. Development of integrated care in our study is neither a result of structural adaptation alone, nor of strategic action alone, but a result of the interactions between concerned actors and their interpretations of structural frames and the actions of others. Implications for policy makers and practitioners are to pay attention to both agency and structure when planning for integration of healthcare services. Limitations: The majority of the informants come from primary care. This could possibly imply a bias towards perspectives from primary care. On the other hand, informants from secondary care are included, and the collaboration initiatives are originally initiated by secondary care. Suggestions for future research: Possible future research includes focusing on how different groups of patients and their carers experience these and other collaboration initiatives. [ABSTRACT FROM AUTHOR]