involved in organizational change: involving physicians versus respecting their time for patient care; slowly building trust versus frustration with slow progress; and building stakeholder buy-in versus building technical capacity (especially when buy-in and trust are enhanced by demonstrated technical capacity and improved performance).

Hospital-Physician Collaboration

Given their importance and obvious potential for problems, a relatively large number of process studies have focused on hospital-physician relationships. A major observation is the importance of developing a climate for change within the partner organizations. In turn, the role of physician leadership is universally noted as critical in developing a supportive climate for change because physician involvement is needed in both governance and management decisions. Results also highlight the importance of putting in place structures (such as incentives) and systems (especially information systems) to support changes in organizational processes and culture. As noted above, investment in management and clinical technologies and core competencies matters, as do shared vision and values.

The work of Devers and her colleagues (1994) stands out for its development of a three-part framework for assessing the extent to which consolidations achieve functional integration (business and management activities, noted above), physician-system integration (alignment of incentives and physician involvement in decision making), and clinical integration (e.g., common protocols). They find much functional integration, but little integration in the other areas—a result similar to that for collaborations among hospitals. The results are discouraging, but it appears that external context can promote change. Pressure from capitation and regulation, in particular, are related to more effective integration.

Concluding Observations from the Literature Review

Several concluding observations about the outcomes associated with collaboration among health care organizations and best practices for improving these outcomes arise from the literature review. First, there is considerable variation in the outcomes of collaborative ventures regardless of the criteria one uses to assess their performance. In fact, many, if not most, of these ventures fail to meet expectations in either the health care or the non-health fields. An exception to this result is mergers among hospitals, which seem to improve their financial performance, though not necessarily to societal advantage because available evidence indicates that improved performance comes mainly from increased market power (increased revenue) rather than efficiency gains per se.

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