Log in

Guidelines For Planning and Developing Integrated Delivery Networks

Mr. Prybil is regional executive and chief executive officer, Daughters of Charity National Health System-East Central, Evansville, IN; Fr. Golden is senior executive for university mission, DePaul University, Chicago, and canonical adviser to DCNHS-East Central; and Sr. Ballance is chair, DCNHS-East Central Board of Directors.

---

Summary

In 1994 the Daughters of Charity National Health System-East Central (DCNHS-East Central) adopted 11 guidelines to help corporate staff and local leaders plan and develop integrated networks.

Guideline 1 emphasizes needs-based strategic planning.

Guideline 2 focuses on the community-based network planning process, recommending a team approach and ongoing communication with the local ordinary.

In guidelines 3 through 5, the DCNHS-East Central Board of Directors spells out key issues that must be covered in proposals ultimately presented for governance action.

Guideline 6 presents three core elements that should characterize all CBNs in which DCNHS-East Central institutions participate.

Guideline 7 emphasizes that all CBN proposals and agreements must be clear with respect to the Catholic identity of DCNHS-East Central institutions.

Guidelines 8 and 9 require that proposed changes to traditional policies and management practices be explicit in CBN proposals.

The tenth guideline requires that all CBN proposals indicate an explicit evaluation function.

The final guideline underscores that regardless of the strategic fit or how well a CBN is designed, it is unlikely to succeed unless both internal and external relationships are based on a solid foundation of honesty, mutual respect, and trust.

---

Throughout the United States, healthcare organizations are forming networks capable of providing an integrated continuum of healthcare services to large population groups. The Catholic Health Association (CHA) and the American Hospital Association both advocate restructuring the healthcare delivery system as a fundamental and essential element of healthcare reform in our nation.¹

The terms that describe the new networks include "integrated delivery networks," "community care networks," and "accountable health plans." Although the terminology and definitions vary somewhat, most leaders advocating reform agree on the importance of certain key features:

• Close linkages among physicians, hospitals, and other providers to build a comprehensive spectrum of coordinated services
• An organizational structure that enables the vertical and horizontal integration of services
• A strong focus on assessing and improving the health status of the community, in addition to caring for individual patients
• The capacity to assume financial risk for providing care to a defined population group or groups

Mission Foundation
The Daughters of Charity National Health System (DCNHS) mission statement proclaims that the fundamental purpose of the system, its regional organizations, and its local healthcare institutions is "to contribute toward improving the health status of individuals and the communities we serve by providing patient-centered, economical health services, with a special concern for the sick and the poor." The statement also calls for all system leaders to "promote a healthy and just society through community-based networks, and collaboration with those who share our values."

Since this mission statement was adopted in 1992, DCNHS has encouraged its entities to forge strong "community-based networks" (CBNs) capable of providing an integrated continuum of services to large population groups.² This priority flows from the conviction that forming integrated networks with partners who share a common vision and compatible values will serve community needs more effectively and efficiently than the fragmented delivery system that has prevailed in the past.

The Daughters of Charity National Health System-East Central (DCNHS-East Central) created 11 guidelines in 1994 to help corporate staff and local leaders plan and develop community-based networks (CBNs). DCNHS-East Central, one of four regional organizations that make up the national system, comprises 21 inpatient facilities and a range of related programs and services in a six-state region.

Guidelines
While crafting the guidelines, the board obtained input from local governance and management leaders, CHA and DCNHS staff, and corporate and canonical legal advisers. The board's intent was to provide parameters that would be clear and helpful, but allow appropriate flexibility at the local level. Following are the guidelines with brief explanations:

1. Community Needs Assessment Community needs and an up-to-date strategic plan should provide the foundation for a DCNHS-East Central institution to initiate or participate in a CBN planning process. The nature and focus of these efforts should be consistent with the overall goals and strategies set forth in the institution's strategic plan.

Just as DCNHS and DCNHS-East Central policies stress the importance of ongoing assessment of community needs as a foundation for local strategic plans, this guideline emphasizes needs-based strategic planning as the basis for planning and developing CBNs.

2. CBN Planning Process The planning process for forming or joining a CBN ordinarily should follow the "General Steps in Major Collaborative Studies" at the end of this article. A team approach involving local and regional representatives will be used to ensure good coordination. Providing regular reports to local, regional, and DCNHS leadership, routinely seeking their advice, and ongoing communication with the local ordinary are key elements in the planning process.

Each community and the manner in which CBNs develop within them are somewhat unique. In general, however, DCNHS-East Central experience suggests that successful planning processes include three major and distinct phases:

• First, potential CBN partners must be identified. Through open dialogue the entities must gain a reasonable degree of mutual assurance that they share compatible visions, values, and principles.
• Second, network partners need to develop an overall plan for a CBN and assess its desirability and feasibility in relation to established criteria.
• Third, if desirability and feasibility have been adequately demonstrated and the respective governance bodies and sponsors approve of the affiliation, implementation planning and due diligence must be completed to provide a solid basis for final approvals before the CBN begins operation.

The steps outlined in "General Steps in Major Collaborative Studies" at the end of this article would be modified when a DCNHS-East Central institution is assessing the possibility of affiliating with an existing network. However, most of the same issues must be addressed and resolved in a satisfactory manner.

3. Improved Services Any proposal to form or join a CBN should document how it would enable healthcare needs to be met more effectively and provide improvements in services to the community, particularly the poor and underserved.

4. Mission, Goals, and Structure Any proposal to form or join a CBN should provide a clear statement of the CBN's mission, goals, and functions, set forth an organizational plan and the rationale for it, and demonstrate that the proposed network is both desirable and feasible.

5. Common Vision and Values Any proposal to form or join a CBN should provide solid evidence that the CBN partners share a common strategic vision, compatible values, and strong commitment to collaboration in serving the community. CBN partners must be comfortable with shared responsibility for setting the CBN's mission/vision, goals and policies, rather than exercising unilateral or dominant control over them.

Guidelines 3 through 5 identify important expectations that must be addressed thoroughly in developing a CBN plan and assessing its desirability and feasibility. Through these guidelines, the DCNHS-East Central Board of Directors, acting on behalf of the canonical sponsor, spells out some matters regarding key issues that must be covered in the proposals that ultimately are presented for governance action.

6. Essential Elements It is recognized that the mission, goals, functions, and organizational structures of CBNs will vary significantly from community to community; however, all CBNs in which DCNHS-East Central institutions participate should (a) embody commitment to improving the health status of the individuals and communities served though providing a comprehensive spectrum of holistic services rather than focusing only on acute care, (b) provide for physician integration and leadership, and (c) enable effective participation in risk-sharing and capitated payment systems.

DCNHS and DCNHS-East Central leaders recognize that networks will vary substantially in both form and function, depending on local needs and circumstances. However, three core elements should characterize all CBNs in which DCNHS-East Central institutions participate. The exact nature of these elements will vary from setting to setting, but the board believes that the long-term success of a CBN will require continual attention to these three elements.

7. Catholic Identity and Sponsorship All CBNs in which DCNHS-East Central institutions participate should reflect the DCNHS mission and values and preserve, protect, and strengthen the Catholic health ministry.³ In this context, any proposal to form or join a CBN should address the traditions of Catholic healthcare and Church teachings, especially as these are expressed in the Ethical and Religious Directives for Catholic Health Care Services and canon law. When DCNHS-East Central institutions become part of a CBN, they will continue to abide by these teachings and directives. Ethical and canonical consultation should be sought in applying the Church's principles of cooperation in relation to any activities of CBN partners that may be proscribed by the directives.

Guideline 7 emphasizes that all CBN proposals and agreements must be clear with respect to the Catholic identity of DCNHS-East Central institutions and their compliance with Catholic teachings and norms. In many communities, the CBNs with which DCNHS-East Central institutions affiliate will include some non-Catholic partners, but the guidelines spell out the expectation that the CBN partners will share compatible strategic vision, values, and principles and have mutual respect for each other's philosophy and heritage. To recognize and underscore these understandings, DCNHS-East Central leaders sought the counsel of CHA staff and canonical advice in formulating this important guideline for planning and developing CBNs.

8. Reserve Powers Any proposal to form or join a CBN and the CBN's actual governing documents must maintain appropriate reserved powers for the DCNHS-East Central Board of Directors acting on behalf of the canonical sponsor, and provide appropriate mechanisms to enable the board to carry out these reserved powers.

9. Roles and Responsibilities It is recognized that, when a DCNHS-East Central institution affiliates with a CBN, the role and responsibilities of local governance and administration will be altered, in some instances substantially. Similarly, CBN linkages sometimes will require adjustments in the application of DCNHS-East Central Policy AL-1, "Levels of Authority and Regional Approval Processes," and/or other system policies and procedures.

When a DCNHS-East Central institution becomes part of a CBN, it must to some extent alter its traditional policies and management practices. Guidelines 8 and 9 recognize this and require that the proposed changes be explicit in CBN proposals presented to the DCNHS-East Central Board of Directors for approval. The exact nature of the changes will vary depending on the structure of the CBN, its role and functions, and the other partners involved. The general principle is that, when a DCNHS-East Central institution affiliates with a CBN, its power shifts from full control of a particular institution to influence over a larger and more complex network.

10. Evaluation Any proposal to form or join a CBN must outline processes for ongoing evaluation and continuous improvement in the CBN's performance to ensure it remains true to its stated mission/vision and goals.

DCNHS-East Central policies embody a commitment to ongoing, objective evaluation and continuous improvement of organizational structures, policies, performance, and partnerships.⁴ Guideline 10 reflects that commitment by requiring that all CBN proposals indicate an explicit evaluation function.

11. Relationships In all aspects of planning, developing, and implementing CBNs, high priority must be devoted to building understanding, commitment, respect, and trust among key constituencies, including employees, local governance and management teams, physicians, parent organizations and sponsors of CBN partners, and community leadership.

Guideline 11 underscores that regardless of the strategic fit or how well a CBN is designed, it is unlikely to succeed unless both internal relationships and relationships with key external constituencies are based on a solid foundation of honesty, mutual respect, and trust.

Understanding, Acceptance
Consultation with local governance and management leaders, when formulating the guidelines, paid off because leaders have reported that they understand and accept them. The guidelines have been communicated within each DCNHS-East Central organization through educational sessions and a variety of other channels. Whenever a DCNHS-East Central entity initiates CBN discussions, the guidelines are shared with the potential partners. This communicates — up front — to potential partners the parameters within which DCNHS-East Central will operate. For both internal and external constituencies, the guidelines are proving to be helpful because they identify the overall expectations of the DCNHS-East Central Board of Directors, acting on behalf of the canonical sponsor, and outline a set of general steps to be followed when forming or joining a network.

As DCNHS-East Central institutions affiliate with CBNs and gain additional experience, the DCNHS-East Central Board of Directors will modify the guidelines from time to time to reflect the lessons our institutions have learned. In the year since the guidelines have been introduced, response has been positive.

For more information about the DCNHS-East Central guidelines for planning and developing integrated networks, contact Lawrence Prybil or Ronald Mead, 812-963-3301.

NOTES

1. See, for example, Catholic Health Association, "Setting Relationships Right: A Proposal for Systemic Healthcare Reform," St. Louis, 1993, Chapter 3; and American Hospital Association, "National Health Care Reform: Refining and Advancing the Vision," Chicago, 1992.
2. Daughters of Charity National Health System, "Community-Based Networks," St. Louis, 1993; and "Community-Based Networks II," St. Louis, 1994.
3. For a useful source document, see Catholic Health Association, "How to Approach Catholic Identity in Changing Times," St. Louis, (a reprint from Health Progress, April 1994).
4. DCNHS-East Central Policy AF-1, "Formal Continuous Improvement Processes," 1992; and DCNHS-East Central Policy AR-2, "Principles and Key Components of Regional Evaluation," 1993.

---

GENERAL STEPS IN MAJOR COLLABORATIVE STUDIES*

1. Identify potential partner(s) for collaboration. Some key questions include: Are their missions compatible with ours? Are their values compatible with ours? Would some form of collaboration be likely to serve the community better and make long-term strategic sense?
2. In concert with the potential partner(s), define the basic premises and principles on which a study of collaboration would be based. Ensure that the other organization(s) is represented by persons who can speak authoritatively for it and that they are truly in accord with these premises and principles.
3. Develop a clear statement of the mission/vision, goals, and functions for a collaborative effort. The intent is to define why we might collaborate and what we would aim to accomplish.
4. Define the plausible alternative structures that might be used to accomplish the defined mission/vision, goals, and functions. (Remember: Form follows function.)
5. Assess the respective advantages and disadvantages of each alternative structure; determine which structure, on balance, appears to be the best.
6. Assess both the desirability and feasibility of a collaboration plan that is based on the defined mission/vision, goals, and functions and the organizational structure that has been determined to be the most appropriate.
7. Provide complete report and recommendations for consideration by the parent organizations and sponsors.
8. If the recommendation is to proceed and this recommendation is adopted by the parent organizations and sponsors, then move into the "implementation planning and due diligence" phase, which will produce detailed operational plans, management team arrangements, budgets, etc.
9. Submit final report and proposed implementation plan to parent organizations and sponsors for final action; if approval is granted, implement the plan and move into a unified mode of operation.

*Continuing communications at appropriate intervals with the local ordinary or his designee and a canon law advisor is vital in all studies of major collaboration. Good communications with the DCNHS national office also are necessary to ensure awareness, coordination, and support (e.g., DCNHS staff involvement in certain "due diligence" activities).