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Completed Projects
The Integration of the New York Harbor Healthcare System
Carol VanDeusen Lukas, EdD,
Elizabeth Adams, MPH
OBJECTIVES: The integration of medical centers is a complex, and often difficult, undertaking, especially in academic medical centers. The leaders of the VA New York Harbor Healthcare System (NYHHS) contracted with the HSR&D Management Decision and Research Center (MDRC) to analyze the integration of the Brooklyn and New York VA medical centers to answer three questions: By what processes did the system integrate? How did integration affect the organization of the system? How did changes in the delivery system and staffing affect the quality of care, patient satisfaction, system efficiency and teaching and research?
METHODS: Using a longitudinal observational design and a case study framework to combine qualitative and quantitative data sources, we tracked the system for 30 months, from March 1999 to October 2001, with updates on progress through December 2002. Analyses were based on data from four sources: 1) Interviews of leaders and staff at the Brooklyn and Manhattan campuses, primarily during site visits to the Harbor in the summers of 1999, 2000 and 2001 and augmented by telephone interviews. 2) Review of integration documents (such as newsletters and planning documents) to extend and corroborate information obtained during interviews. 3) Surveys of employees across the system in the summers of 1999, 2000 and 2001; approximately 800 employees at all levels of the organization responded to each survey. 4) Analysis of VHA administrative databases to obtain information about NYHHS characteristics and performance on standard VHA measures.
FINDINGS/RESULTS: NYHHS merged almost all administrative services and selected clinical services across campuses by early 2002. It maintained both the Brooklyn and Manhattan campuses as acute inpatient facilities with independent Medicine and Surgery services, with some specialized clinical niches at each campus. By design, medical education was not substantially changed. Many forces affected integration. Forces working against integration included: system characteristics (similarity of size and complexity of the two campuses, strong academic affiliations with two medical schools, differences in organizational cultures, geographic distances); medical school leadership and faculty advocating for the status quo; and union resistance to change. Forces facilitating integration included: Harbor leadership; integration planning and implementation processes (the integration office, the integration teams and steering committee; communication with employees, creating synergies across campuses); JCAHO review; budget constraints. The strategy of targeted opportunities in deciding which clinical services to integrate worked both for and against integration. Comparing system performance in FY2001 with performance of the two medical centers in FY1998, before integration, system efficiency improved and patient satisfaction was mixed.
CONCLUSION: With strong forces arrayed against integration, NYHHS made good progress in creating an integrated system, especially across its administrative structures. Integration improved system efficiency. The JCAHO review was a significant facilitator in bringing staff together and creating uniform policies and consolidated committees across campuses. The commitment to minimizing the impact of integration on the core teaching programs limited clinical integration.
IMPACT: Study findings presented to NYHHS leadership throughout the study provided regular feedback on the progress of integration. Study findings were also regularly communicated to staff across the system.
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