Skip to main content

Table 1 Sample indicators for each key principle

From: Indicators and measurement tools for health system integration: a knowledge synthesis protocol

Key principle Description of the principle Sample indicators
1. Comprehensive services across the care continuum • Cooperation between health and social care organizations
• Access to care continuum with multiple points of access
• Emphasis on wellness, health promotion, and primary care
• Coordinated transitions in care across services [23]
• Shared programs across sectors/services [24]
• Third next available appointment [25]
• Emergency department average LOS registration to discharge; registration to admission (QPSD 23) [26]
• Measure wait time for referral to treatment by provider type (QPSD 20) [26]
• Proportion of patients with health outcomes which are avoidable given the current state of medical knowledge and access to appropriate care [27]
• Tobacco screening [28]
2. Patient focus • Patient-centred philosophy; focusing on patients’ needs
• Patient engagement and participation
• Population-based needs for assessment; focus on defined population
• Involvement in care planning for chronic disease/complex care [29]
• Evidence of a population-based needs assessment [30, 31]
3. Geographic coverage and rostering • Maximize patient accessibility and minimize duplication of services
• Roster: responsibility for identified population; right of patient to choose and exit
• Existence of primary care network structures (e.g. family health teams, primary care networks, GP Divisions, inner city primary health care clinics) [30]
4. Standardized care delivery through interprofessional teams • Interprofessional teams across the continuum of care
• Provider-developed, evidence-based care guidelines and protocols to enforce one standard of care, regardless of where patients are treated
• Team effectiveness [32]
• Using a shared clinical pathway across care sectors (e.g. diabetes care, asthma care) [33]
5. Performance management • Committed to quality of services, evaluation, and continuous care
• Diagnosis, treatment, and care interventions linked to clinical outcomes
• Performance measurement indicators and tools are in place and being used regularly [34]
• Clinical outcomes being measured [35]
6. Information systems • State-of-the-art information systems to collect, track, and report activities
• Efficient information systems that enhance communication and information flow across the continuum of care
• Shared information systems across care sectors [36, 37]
7. Organizational culture and leadership • Organizational support with demonstration of commitment
• Leaders with vision who are able to instil a strong, cohesive culture
• Extent to which organizational goals and objectives are aligned across care sectors [36]
8. Physician integration • Physicians are the gateway to integrated health care delivery systems
• Pivotal in the creation and maintenance of a single-point-of-entry or universal electronic patient record
• Engage physicians in leading role, participation on Board to promote buy-in
• Physician integration within care teams and across care sectors [10, 36, 38]
• Practitioner payment models that support integration [37]
9. Governance structure • Strong, focused, diverse governance represented by a comprehensive membership from all stakeholder groups
• Organizational structure that promotes coordination across settings and levels of care
• Existence of interagency agreements, service delivery team coalitions [39]
• Governance model that includes representation of communities served [30]
• Evidence of governance in monitoring and evaluation of health system [40]
10. Financial management • Aligning service funding to ensure equitable funding distribution for different services or levels of services
• Funding mechanisms must promote interprofessional teamwork and health promotion
• Sufficient funding to ensure adequate resources for sustainable change
• Extent to which financial management is coordinated across care units and sectors [36]
11. Overall integration   • Degree of integration within the health system and across sectors [41, 42]