Managing intergroup silos to improve patient flow.

Abstract

Health care managers face the critical challenge of overcoming divisions among the many groups involved in patient care, a problem intensified when patients must flow across multiple settings. Surprisingly, however, the patient flow literature rarely engages with its intergroup dimension. This study explored how managers with responsibility for patient flow understand and approach intergroup divisions and "silo-ing" in health care. We conducted in-depth interviews with 300 purposively sampled senior, middle, and frontline managers across 10 Canadian health jurisdictions. We undertook thematic analysis using sensitizing concepts drawn from the social identity approach. Silos, at multiple levels, were reported in every jurisdiction. The main strategies for ameliorating silos were provision of formal opportunities for staff collaboration, persuasive messages stressing shared values or responsibilities, and structural reorganization to redraw group boundaries. Participants emphasized the benefits of the first two but described structural change as neither necessary nor sufficient for improved collaboration. Silos, though an unavoidable feature of organizational life, can be managed and mitigated. However, a key challenge in redefining groups is that the easiest place to draw boundaries from a social identity perspective may not be the best place from one of system design. Narrowly defined groups forge strong identities more easily, but broader groups facilitate coordination of care by minimizing the number of boundaries patients must traverse. A thoughtfully designed combination of strategies may help to improve intergroup relations and their impact on flow. It may be ideal to foster a "mosaic" identity that affirms group allegiances at multiple levels.