Why bother about governance - exploring interpretation of professionals involved in the implementation of integrated care programmes in community healthcare organisations

摘要

The last five years in Ireland has seen drives towards effective service delivery through integrated care arrangements for the purpose of improved care quality. The CHO report popularly referred to as the Healy report, published in 2014 emphasizes the importance of the reorganisation of community-based service and it recommends the establishment of nine CHOs as well as the governance and management arrangements. Implementation literature in Ireland highlights that there is insufficient empirical evidence to capture the gains of integrated care in Ireland. There are calls for more research focused on organisation wide research programmes, increase in the number of researchers engaged in systems research (2, 3) and further assessment of governance arrangements (2-5). While there are investments in reforms, evidence highlights that the process of implementation diverges in practice (6) and reforms do not seem to curb challenges in the health system (4, 6, 7). Engagement in research is able to provide a loop of learning, which could inform future policy process of integrated care. In this paper, the researcher explores the interpretation of frontline professionals situated in Community Healthcare Organisations (CHOs) as they implement integrated care in Ireland. This study utilises a strategic management approach (Strategy As Practice) and draws on institutional theory as well as social theories of practice and sense making. To explore implementation, a qualitative interpretive research approach was utilised in two phases and data was thematically analysed. Using a qualitative exploratory research design, the researcher has been able to identify themes related to various aspect of implementation of integrated care. Awareness, understanding and actioning (processes and practices of professionals who are situated at different levels of implementation). Overall, there is a positive embrace and support of the change agenda. Findings highlighted lack of adequate information, communication and clear rationale before the implementation of recommendations of Healy report. Insufficient local level support to govern and make considerable changes. Implementation of the report still seems slow, lacking in the engagement of frontline/middle level managers and their involvement in decision-making. Awareness of clinical governance is still relatively low and interest in governance is dependent on its relevance to the role of professionals as well as lack of relationship between the document and their day-to-day activities. Professionals expected to implement at local level are unaware of the actioning plan at the CHO level and there is insufficient update or communication on the progression of the implementation process. There is the need for improvement on the culture around issues of governance, involvement of professionals at all levels in the health system on matters relating to governance regardless of their level of engagement with decision-making. More open decision-making as well as adequate risk assessments because current arrangements are perceived to be vague. Frontline professionals cannot overemphasize the importance of local level engagement and co-creation or involvement in the entire policy process. A larger project will give a clearer exploration of governance arrangement in the Irish healthcare.