ABSTRACT
Transforming outcomes for patients by aligning and integrating care requires complex systems change and management across multiple organisational boundaries. This case study outlines one part of the integration journey across a partnership between three independent NHS foundation trusts with strong affiliations to two universities, the combined expertise of which places them at the forefront of being able to deliver the best heart and lung outcomes for patients. It specifically describes the process of designing, testing and implementing a bespoke tool called the Clinical Academic Integration Framework (CAIF) to support clinical and academic teams in owning, planning and delivering their paths to full integration, defined as ‘one team, across multiple sites’ in this context.
Introduction
Partnership working across organisational boundaries is increasingly important given the policy focus on integration, through mergers or across systems of care.1–4 In 2018, a partnership was formed between the Royal Brompton & Harefield NHS Foundation Trust and King's Health Partners (KHP) to transform the care received by patients living with cardiovascular and respiratory diseases. This unique opportunity combined the partners' expertise in clinical care, research and education to deliver the Partnership's vision: Delivering the best cardiovascular and respiratory outcomes for patients, wherever they receive care, improving the health and wellbeing of patients throughout their lifetime.
At the outset, the partnership comprised three independent NHS Foundation Trusts delivering a range of community to tertiary and quaternary services over multiple, geographically dispersed sites, and strong research and education links to two universities as part of two Academic Health Science Centres, including one formally part of the Partnership. As such, delivering this vision requires complex systems change managed across multiple organisational boundaries, while enabling clinical and academic teams to own and deliver change. Teams were supported to integrate as ‘one team, across multiple sites’, maximising partnership opportunities for patients and staff, while recognising the heterogeneity of teams and different interpretations of end goals.
Although many high-level theoretical models describe how provider organisations might work together,5 there are fewer practical tools designed to enable frontline staff to develop and lead change across organisational boundaries according to their local circumstances. Furthermore, many models focus on clinical service configuration or improvement,6 and are less focused on how to maximise opportunities across a clinical academic model, by including research and education. Therefore, a bespoke tool was designed to support multidisciplinary teams to design their own pathways to integration, as part of a wider complex systems approach.
Solution/methodology
The development of the tool had three main phases: design, iterative testing and implementation (Fig 1).
A summary of each phase of the Clinical Academic Integration Framework (CAIF) tool development.
Designing the framework
To be useful, tools require careful and systematic adaptation to local context.7 Various care models have been developed across the NHS in England aimed at different ways of integration that breaks the cycle of traditional silos,8 given that traditional project management tools often lack the agility needed when working in a highly complex and dynamic environment.9 Joint working and co-production can be facilitated or hindered by the system surrounding it and the wider community that supports it,10 whereas softer aspects of integration, such as differing cultures, can often be what hinders integration.11 As such, to support teams, the Partnership recognised an opportunity to develop a bespoke tool that would enable teams to conceptualise the work required to integrate with others not only clinically, but across research and education. The tool needed to be applicable to all teams within the Partnership and, therefore, would need to be adaptable and reflect the diversity of team structures and ways of working, while also acknowledging that some teams are already more integrated than others. We followed Best et al's ‘simple rules’ for success in systems transformation:12
Blending designated leadership with distributed leadership by defining the organisational level at which integration is expected to be delivered (subspeciality/pathway, directorate, organisation or Partnership wide)
Promoting feedback loops by identifying clear milestones and encouraging teams to adapt the framework to reflect individual teams’ contexts
Encouraging broad engagement and involvement of multidisciplinary teams, the public and patients, in defining and undertaking integration journeys
The first version of the Clinical Academic Integration Framework (CAIF) describes suggested different ‘levels’ of integration ranging from Level 0 (services running separately) to Level 4 (single service) across several dimensions: operational; workforce; governance; research; and education and training (Fig 2). Table 1 summarises the methods used to design the framework, primarily being extensive engagement with multidisciplinary clinical academic teams and patients.
The first version of the Clinical Academic Integration Framework (CAIF) developed in 2019 with definitions for each of the dimensions.
Summary of the approaches used to develop the Clinical Academic Integration Framework (CAIF), including a review of the literature, extensive engagement with clinical and academic teams, and reflection and refinement based on learning and feedback
Testing the framework
The CAIF was iteratively tested over 13 interactive sessions with over 40 multidisciplinary team members. Stakeholders were asked to review the CAIF in detail and feedback on its content, usability and relevance. This feedback was used to improve the framework (Table 2) and identify discrete areas requiring alignment to demonstrate fully integrated services. The first iteration of the CAIF grouped milestones into four dimensions and identified incremental steps (assigned to different levels of integration) for achieving them. Table 3, demonstrates what ‘one team, multiple sites’ looks like, and includes indicative milestones that can be tailored for different teams based on their objectives.
Stakeholder feedback log from Clinical Academic Integration Framework (CAIF) testing phase
‘What does one team, multiple sites look like?’ with indicative key milestones.
One major iteration in the testing phase following feedback was to focus the tool on what was in the control of clinical and academic teams at the clinical subspecialty level. Although it was useful to include dimensions relating to organisational level developments, such as governance, it became clear that the tool was most impactful when focused on what could be achieved in advance of any major organisational change or policy development. Therefore, in the second iteration, the tool placed less focus on ‘governance’ as a dimension.
Outcome
Implementation of the framework
The CAIF has been used by multidisciplinary teams from 22 cardiovascular and respiratory subspecialities to develop their integration plans as they work toward full integration. The CAIF does not prescribe an approach for teams to achieve these milestones, but encourages them to tailor their approaches depending on their baseline (current level of integration), existing relationships and current ways of working.13 The final framework incorporates feedback from groups following its use in practice after 1 year. It groups integration activities into five main dimensions using a five-point scale, which demonstrates a continuum from full segregation (Level 0: minimal awareness) to full integration (Level 4: embedded practice and iteration)14 as seen in Fig 3. These levels enable teams to break down integration into incremental steps so that they can plan their journey and demonstrate tangible progress.
The second iteration of the Clinical Academic Integration Framework (CAIF) and dimensions following 1 year of implementation.
The full framework (available on request) offers descriptions of each of the dimensions (operational, workforce, research, education and training, and governance) but it is neither comprehensive nor exhaustive. It is intended to highlight important areas to think about when integrating services and the plan actions needed to achieve ‘one team, multiple sites.’ In practice, the implementation of this framework needs to be supported by comprehensive staff and patient engagement, organisational development, communications and separate tools to plan, track and manage the objectives, benefits and risks throughout the integration journey. Table 4 outlines what it would feel like for clinical teams as they move along their integration journey.
What would it feel like for clinical teams at each level of integration?
Observations
Key reflections were identified on the use of the tool. First, we found that progression through the tool was not linear in that teams moved through the levels of integration at different paces for each domain. This nonlinear progression reflects both the context of each team and the interdependencies between aspects of integrated services. For example, it is necessary to align pathways and protocols (Level 3, operational) and have standardised terms and conditions (Level 4, workforce) before it is possible to undertake partnership-wide job planning (Level 4, workforce).
Second, big strides could be made through disruptive innovation. During the Coronavirus 2019 (COVID-19) pandemic, we observed that several teams made significant progress toward full integration. This was catalysed both by necessity and increased access to digital innovation. For example, several teams that had never worked together (Level 1, joint team working) are now holding regular joint multidisciplinary meetings (MDMs) (Level 3, joint team working,) because of the rapid implementation of various digital platforms.
Third, teams valued the flexible nature of the tool as a key part of its usability, specifically in being able to use it in different ways as a way of bringing key information to light. For example, in developing their plans, some teams performed pathway mapping15 to identify similarities and differences in current pathways, and understand the current level of integration. Other teams identified priorities by selecting ‘key milestones’ that particularly resonated with their local context and experience, such as cross-site rotations. Integration plans were jointly developed by integrating teams to ensure a sense of ownership and connectedness to promote implementation.
Conclusion and next steps
The CAIF is designed as a generic tool that can be used by any clinical academic team irrespective of their professional background, speciality, size or composition. It is neither exhaustive nor comprehensive, but a living document to be adapted with use. It is intended to be a practical tool for teams to understand the requirements for more than one team working in functionally similar services to form a single team. It does this by providing an overview of many components of work required to integrate services while simultaneously breaking them down into manageable steps that are set out in a logical order shown by the levels of integration.
Integrating clinical teams is a long-term endeavour that will take several years to achieve. The CAIF has been designed to be used over this journey. As teams progress through the integration levels, the framework can be used as a tool to evaluate the extent of integration across several dimensions. Next steps are to formally evaluate the effectiveness of the CAIF, to understand what supported clinical teams in their journey to integration and what could be improved.
Acknowledgements
The authors would like to acknowledge the contributions of many colleagues who have co-created the CAIF framework, including: Alice Ward, Amanda Dumont, Ben Anderson, David Hardy, Elaine Jenkins ApRees, Emma Fletcher, Emma Saunders, George Lenon, Hassan Al Omari, India Miller, James Glass, Joanna Ward, Lauren Pittman, Loretta Gyambibi, Lucy Thorp, Mark Smith, Natali Chung, Richard Beale, Richard Grocott-Mason, Sarah Bowker, Steve Wilkerson, Stephen Sutherland, Tiago Ferreira deSousa, Venessa Vas, clinical and academic teams across adult and children's cardiovascular, critical care, imaging, pharmacy, respiratory, and rehabilitation and therapies services.
- © Royal College of Physicians 2023. All rights reserved.
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