Development of interorganisational integration—a vocational rehabilitation project

Abstract

The aim of this thesis was to describe and analyse the development of interorganisational integration in a vocational rehabilitation project built on empirical data. The project was one of several structural efforts that were launched in Sweden in the 1990s to increase integration between different organisations regarding vocational rehabilitation. The goal was to obtain advantages for both clients and society through coordination of joint resources. To understand the development of interorganisational integration four studies were performed based on data collection from four years. The specific objectives were to analyse: (i) variation in views on long-term goals, (ii) different views on clients, (iii) the perceived barriers to the progress of the project and (iv) to describe and analyse the organising of the project over time. Each of the four objectives was undertaken as a separate study during the research. The project involved four different organisations: social services, social insurance, the employment service, and health care. A qualitative approach was used to data collection. In total, 51 interviews and 14 focus group discussions were performed including studies of documents. Interviews and focus group discussions were performed with actors at different levels in the different organisations. A phenomenographic approach was used for analysis in the first two studies. The third study was analysed with a thematic analysis. For the fourth study a chronological case study of the process of organising was used to get a more holistic picture of the project. The results of the case study description were analysed in order to find patterns in answer to the questions how and why the organising was done in the way it was. The results of study I and II show that the project had an unsteady base as the actors had qualitatively different views on goals and clients at the outset of the project. Study III points to three barriers to the development of integration that existed throughout the project: uncertainty (for example, in goals and leadership); lack of communication and prioritisation of one’s own organisation. There was a circular relationship between the barriers as focus on the actor’s own organisation led to flawed communication, which in turn led to uncertainty within the project. Territoriality and excessive focus on formalities and finances were consequences of this. The results of study IV show that the project was reorganised every year—partly in order to gain economic control, but also as the result of power struggles. The project was built as a bureaucratic organisation of its own with different hierarchical levels. Three main themes emerged from the analysis: development of the process of the project, organisation and communication, conflicts and leadership. Conclusions relevant for integrated care were that the four studies combined to reveal a project where the original desirable focus on clients had changed to a focus on rules and structures in a bureaucratic way. The development of interorganisational integration resulted in scattered islands of interprofessional work in teams with no connection to one another. Thus, the vertical integration was greater than the horizontal. Implications for integrated care would be that in developing interorganisational integration, it is important to have a holistic and comprehensive picture of the complexity of a project in its context and to understand the added value of working in a seamless way instead of working for short-term gain in each department or organisation. In the process of changing ways of working there is also a need for change management that promotes client focus, interaction and communication as well as transparency of decisions and actions. The results presented in this review are based on the author’s thesis presented at the Nordic School of Public Health, Gothenburg, Sweden, on 27 March 2009. Full text available from: http://www.nhv.se/upload/dokument/forskning/Publikationer/DrPH-avhandlingar/DigitalKappa0902.pdf. Further articles by this author in the International Journal of Integrated Care: Wihlman U, Stålsby Lundborg C, Axelsson R, Holmström I. Barriers of interorganisational integration for vocational rehabilitation. International Journal of Integrated Care [serial online] 2008 Jun 19;8. Available from: http://www.ijic.org/. Sandström U, Axelsson R, Stålsby C. Interorganisational integration for rehabilitation in Sweden—variation in views on long-term goals. International Journal of Integrated Care [serial online] 2004 Dec 15;4. Available from: http://www.ijic.org/.