The soft side of integration

By Dr. Joshua Tepper

Health care systems across the country and in many places around the world are increasingly turning to integration as the next frontier in health system restructuring and modernization. In Ontario alone, a recent call for expressions of interest to create integrated Ontario Health Teams is rumoured to have had more than 150 respondents representing a few hundred service providers across all sectors (with no sticks or carrots offered to motivate the applicants).

It is hoped that a well integrated health system will tick all four boxes of the quadruple aim: improved population health, improved patient experience, improved provider experience and better value.

The exact structure and vision for integration is variable and what these models are called varies even more widely. In almost all cases, hospitals invariably play a critical role in the design and execution of integrated care models.

Much of the attention of integration focuses on big ticket items – founding models, legislative changes, governance structures, information technology platforms and labour relations issues. Undoubtedly, these are critical parts of the answer and are critically necessary elements to address. But focusing on these larger issues often feels disempowering for those closer to the front lines where local community service providers are trying to move forward. The reality is that while these ‘big ticket’ items need to get addressed as key enablers, those will be necessary but not sufficient factors to bring integration models to fruition. Some of the really critical success factors are actually things that will happen at the community level. Here are a few of the local, ‘softer’, activities that might help integration succeed:

  • Giving up space – Integrated care models are going to require different sets of players working in different ways and taking on different roles. While the temptation will be for avaricious positioning for more money, power, prestige, market share, etc., in fact what will often be needed is for some groups to give up space, to relinquish historical roles and to allow new voices to be heard.
  • Starting with the patient voice Many individual parts of the system have begun the process of patient engagement with patient experience surveys, patient and family advisory committees, and starting board meetings with patient stories. How do we continue that momentum in the process of creating integrated models? How do we identify patients interested and appropriate for this work? How do we prepare them to participate? How do we make sure their involvement is meaningful?
  • Setting goals and defining success – While many of the macro goals and accountability frameworks will be set by governments or their agents, there is an opportunity to also define what success looks like locally. It may be about focusing on a particular local health need, establishing certain engagement strategies or creating new communication channels in the community.


  • Stopping to celebrate success and learn from failure – Creating a truly integrated health system is going to be the work of a decade. Governments will come and go, leaders will change and context will evolve. Its going to be a journey. We will need to manage our expectations –  there will be more singles than home runs and plenty of strike outs. There will also be some really wonderful successes. We need to make sure we support each other and learn on the hard moments – not criticize or gloss them over. We also need to come together and take joy when things go right.
  • Create the rules of engagement – If things like legislation and funding formulas are creating a sandbox, then locally we need to figure out how we want to play in the sandbox: the values we want to share, the rules we want to follow, the culture we want to see. This is going to vary community by community but it is going to be glue that holds each community together. It is easy to undervalue spending time creating and articulating things like principles and shared values. We need to invest energy thinking about and articulating these things. As a colleague said, these initiatives are going to move at the speed of trust and we need to create an environment where trust can be built.

These things might all be seen as the ‘soft’ stuff but at the end of the day they will matter a lot if integration is really going to succeed.


Dr. Joshua Tepper is the President and CEO of North York General Hospital.