Creating Systemness: Eight Practices to Make Integration Work

Contributors: Jennifer Tomasik, SM, FACHE and Lynn Oppenheim, WG’81, PhD
To learn more about Jennifer and Lynn, click here.


cobweb-2034015_1920.jpgnewly merged academic health center was struggling to keep all the pieces together after a number of acquisitions and mergers. Attempts to streamline its back office services to support a more robust and integrated set of clinical and educational offerings for population health were stuck. As with many mergers, the financial and operational due diligence considered the technical issues at hand, but it largely ignored the cultural issues the leaders would face when they tried to act as a system.

When the merger went live, leaders faced a number of challenges as they tried to bring the different parts of the organization together. Expectations were ambiguous, which led to distrust among colleagues. Systems were difficult to reconcile, old informal systems and networks (think — reaching out to “Joe” who can help me resolve this problem) broke down, and the work-arounds needed to get things done made other process challenges even more apparent. Productivity declined, faculty were frustrated, and administrators struggled to discern how to close the gap between where they were and the potential they knew they could achieve.

Formal organizational ties are only the first step
The promise of population health has led large health system and academic medical centers to engage in many different forms of mergers, acquisitions, and partnerships (MAP) in an attempt to provide care across the continuum. While MAP may be necessary to support population health, it is not sufficient by itself. The ties that bind successful MAP results come from work focused on building shared culture, structure, and processes to build a system that is a whole greater than the sum of its parts. Culture plays a particularly important role, as it expresses the practices that reveal “the way we do things [or want to do things] around here.” Practices are the building blocks of culture, reflecting two critical elements: behavior (how people do their work) and supports (the infrastructure and organizational supports that make those behaviors possible). If you want to change the culture, you have to change practice. 

Eight practices to make it work
While there is no step-by-step recipe for integration, we understand what it takes to make it work. Partnering with our clients who strive to realize the value of their MAP activities and build strong cultures to support them, has revealed eight practices that can increase the likelihood of success:

  1. Leadership commitment — Without leadership conspicuously supporting the process, there are too many forces that can hinder the process. We have found it particularly powerful when leadership commitment was visible across functions and entities, often in the form of a steering or oversight committee. This helped those in the process recognize that, wherever they sat, those in their chain of command were on board. 
  2. Getting the system in the room — We often imagine we are sensitive to the needs of others and will adequately represent their interests. At the most abstract level, that may be accurate. However, the ramifications of integration show up in unpredictable ways. Helping people speak for themselves, their roles, and what makes it easier or more difficult, more aligned with their objectives or less, usually gets you a lot closer to their perspective, and demonstrates a measure of respect for those involved. 
  3. Understanding the barriers — One of the most valuable tools we have used is “Backcasting,” wherein groups who are close to the action identify the barriers to a goal of integration and the accomplishments that overcome those barriers. Backcasting produces a clear and actionable plan for moving forward and identifies what needs to be done and who can do it.
  4. Better tools and systems — We can work very hard on the human parts of the system, but if they are not supported by the technologies in place, frustration will continue and it will be difficult to sustain the commitment.
  5. Commitment to transparency — In merging organizations, the “tops” are often more distant than ever before from those in the middle, having not yet earned the trust of those from other entities. After the (often necessary) secrecy of the transactions themselves, a commitment to transparency is a welcome change. When the commitment is followed up by actions, it starts to build the trust needed for staff to transfer their loyalties and bring their best to their roles.
  6. Clarifying expectations — We’ve discussed the challenge of clarifying expectations and the effect it has on trust among colleagues. We have found that simple Service Level Agreements can help people clarify what they need from each other and understand the challenges others have in meeting what seem like reasonable demands.
  7. Allowing for variation — In every health system in which we have worked, metaphors appear for recognizing that the same exact processes cannot be applied uniformly — from “hard core/soft periphery” to “variegated,” etc. A good process helps establish where uniqueness is necessary and where it is not. Acknowledging from the start that completely uniform processes won’t be required helps address a core tension for many who fear the loss of what they need to do their jobs effectively.
  8. Learning from each other — One of the most powerful advantages a large system has is its ability to benchmark within the system, to learn who does what well and what others can aspire to. When we allow the benchmark to come from any place in the system, we have groups and entities who can collaborate as learners and teachers — the roles reversing depending on the metric.

Why it’s so important
With integration so clearly a struggle, let’s review why it’s so important. Integration matters to both the clinical operations — where one entity needs to know its hand-offs are well received across the continuum — and to operations — where leadership needs a clear and consistent picture of the whole organization. When a system is well integrated, there are the advantages of both organizational and individual learning. And learning is one of the factors that keeps academic health systems at the forefront of an ever-changing field.

For more information on this topic or related materials, contact CFAR at [email protected] or 215.320.3200 or visit our website at