A holistic approach is the best approach for achieving appropriate consumer outcomes in health. This may require that different services, health professionals and consumers interact to enable outcomes to be achieved. These people or health services directly involved in provision of care are stakeholders.
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There are arguments for the inclusion or exclusion of stakeholders in community care health services. The exclusion of stakeholders allows the health service to focus on service delivery, a service that reflects their vision and goals and does not require knowledge or understanding of others. By involving only those who share the same vision and goals ‘enables high levels of openness within groups, and increases the fruitfulness of discussion (Quixley 2009)’.
Community care health services that have and promote a culture of inclusiveness enable stakeholders to learn and become accepting of alternate perspectives. Inclusiveness ensures that the service and provision of care does not become insular and risks the promotion of self interest for individuals. A community care health service that ‘sees its approach as the only way to do things’… rejects a ‘culture of openness that protects against secrecy and hidden agendas (Quixley 2009)’.
There are many aspects to consider with respect to stakeholder relationships and where challenges exist, the result can be compromised quality in service provided to the health consumer.
It is the intention of this essay to discuss from an inclusive perspective, key challenges to developing and keeping stakeholder relationships and strategies that can be adopted to improve these relationships. Key challenges identified for the purpose of this discussion relate to interprofessional collaboration, scope of practice, service coordination/care planning, governance and team practice.
Interprofessional collaboration between health care services is an important aspect of providing quality care for consumers. To achieve the best outcomes for the consumer it may be necessary for health professionals from various services to engage collaboratively with each other. This interaction ensures continued and up to date relay of information that informs all stakeholders of the health status of the individual.
The argument for collaboration or service integration versus a categorical (traditional) view of service delivery is largely based on the …natural and undeniable interconnectedness between service providers, trainers, clients, families, communities and other stakeholders in society. (Stone 2009)
An obstacle often related to the break down in interprofessional collaboration is professional arrogance. Health professionals like all other professionals have their own professional identity. This identity is based on values, roles etc learnt during their own period of training and education.
Often referred to as the progression of the ‘socialisation process’ (Stone 2009), for the health professional this can transfer negatively, where at times the professional is unable to understand another’s professional perspective and this impacts on relay of information and the stakeholder relationship.
If stakeholder relationships are to be maintained it is important that professional arrogance be removed. Strategies to address professional arrogance and improve stakeholder relationships can be included in recruitment, training and effective communication.
The recruitment process and continued training for these valuable members of a health care team needs to firstly, strongly emphasise teamwork as being an essential aspect for achieving consumer outcomes. Equally important, is that each professional clearly understand the vision of each agency represented, and that everyone respects the professional skill, knowledge and commitment to each profession. All selection criteria should require the applicant to understand agency vision, clearly state roles, responsibilities and teamwork approach to service delivery.
Inter-agency meetings provide an avenue for care team professionals to support each other. This creates an opportunity to promote mutual respect and trust among each professional group and further maintains the focus on consumer needs.
Scope of knowledge can be a barrier to the consumer and their needs should always be the foremost priority in health care. These needs can be undermined when there are challenges that impact on stakeholder relationships in rural and remote areas. In these geographical areas the recruitment and retention of professional health expertise is often a challenge in itself, and further challenged by the need for existing staff to work outside what is normally considered their individual or professional scope of knowledge.
In a team environment, it is important to have an understanding of your own scope of knowledge as well as the scope of practice of other team members. (SARRAH 2010)
Where there is existing broad or unclear scope of practice for health service team members it becomes difficult to maintain clear roles and responsibilities in relation to provision of care.
Where gaps exist in competence and practice, organisational support through further training opportunities will address individual skills required.
Through the provision of support to address these gaps, the delegation of tasks can be based on trust and assurance that the professional is providing care that is in the best interest of the client.
Health care team members who have confidence in the scope of practice of each participant will improve stakeholder relationships and further promote consumer confidence.
The consumer is the primary stakeholder in health care, although unfortunate, in some cases, consumers are not always supported in the decision making relationship between themselves and service providers.
Service delivery needs to be driven by the needs of consumers and the community rather than the needs of the system, or those who practice in it. (Primary Care Partnership Victoria 2009)
Barriers to service coordination and care planning need to be addressed to ensure that the best health outcome for the consumer is reached and to contribute to the maintenance of stakeholder relationships.
Health care team participants should ensure that capacity building programs are provided for consumers. Capacity building provides the tools that enable informed decision making on the part of the consumer.
Through the provision of capacity building programs the consumer should be better prepared to determine their own health needs. Care planning is an integral measure that is adopted to meet consumer needs but care planning can only be successful if the consumer and all health care team members share the same goals.
Care planning sessions or meetings provide all inter-service participants an opportunity to clarify all aspects of care needs. Some issues that can be determined are roles and responsibilities, position descriptions and choice of service provider, all aspects of collaborative care.
At planning sessions all communication should be open, respectful of different perspectives and change of ideas, this allows for consensus among all participants.
Further to care planning sessions, regular reviews that involve all inter-service health professionals allows for continued information relay about any changes to care needs. Stakeholder relationships are important in health care planning and can be promoted if these measures are taken.
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‘Team member’s value and nurture interprofessional collaboration (Smith et al 2008)’ and continually engage in team building strategies. Although these are important aspects of governance, stakeholder relationships can become challenged if strategies are not introduced that address governance issues.
Other strategies that can be employed are (a) Principles of effective consultation can address barriers that reflect ineffective – eg governance; (b) cultural barriers, including protection of territory is damaging to relationships if health care team members are not all equal in power; (c) all health care team participants should have equal share of power. Decentralisation of power promotes a sense of joint ownership ensuring professional safety to all, (d) through the development of protocols and procedures, methods introduced can be duplicated by all inter-service stakeholders to complete tasks like consumer referral, this ensures consistency in approach; and, (e) participatory processes inclusive of meetings, maximises the contribution of expertise by all professionals and allows involvement of each member.
When engaging in participatory processes all health professionals should present as individuals rather than experts, disregard for the hierarchical system is an effective strategy that contributes to effective consultation and governance. Accountability goes hand- in-hand with responsibility. By attending and participating in these meetings, health professionals become accountable and responsible for actions taken in consumer care provision.
Participatory meetings also provide a forum for discussion between services and professionals about funding mechanisms. All health care should be cost effective and these discussions can prevent valuable resources being wasted and eliminate duplicated or overlap in service provision.
How community care health services conduct their affairs is important to stakeholder relationships. Governance of these services can directly influence and create barriers to the collaborative process.
The majority of community care health services are funded by government and as such must meet all requirements of funding and service agreements. These agreements may stipulate that in order for the service to receive funding the service must meet performance targets, disclosure and governance requirements that include annual general meetings, audits and the lodgement of annual returns. All future funding for services is dependant on meeting requirements of funding and service agreements.
When regulatory requirements are not met… the funding body can appoint an administrator to wind up the agency and distribute its assets. (Vic Government 2010)
The winding up of a community care health service results in staff redundancies where service representatives must vacate their membership in the health care team. When members vacate this disturbs the continuum of collaborative care and greatly affects stakeholder relationships.
Governance must be appropriate and include effective strategies that maximises contribution, decentralises power and incorporates processes and protocols for the health care team and the services that members represent. These strategies are factors that promote the maintenance of stakeholder relationships.
Working as a team in the delivery of health services is a cornerstone of primary health care. Dysfunctional teams compound the considerable challenges that already exist for health professionals and health consumers. (SARRAH 2010)
To effect positive team practice appropriate measures inclusive of clear goals and visions should be developed that enhance rather than impact on inter-service relationships and consumer outcomes. Considerations for effective team practice involve communication, conflict resolution and change management. For the promotion of positive stakeholder relationships every team needs sound leadership. Dependent on the expertise of team members shared leadership roles should be supported. For team members, shared leadership is a strategy that can contribute to the maintenance of personal health, alleviate stress and reduce staff turnover. Disruption, variances to accepted procedures and loss of knowledge of policies are all a result of staff turnover.
The promulgation of information that clearly outlines goals, policies and strategies will ensure that all new members understand what is required and how it is done, all necessary to the maintenance of stakeholder relationships. Reflective practice, another strategy, recognises existing or potential problems and is a skill that all team members should possess. Group sessions, where open discussion can be held regarding care situations that did not go well for the health professional provides the opportunity for problem solving. Engaging in these sessions is also an opportunity to assess the strengths and weaknesses in service provision and influences changes intra and inter-service that may be required.
Other strategies include (a) Engaging in reflective practice is beneficial and assists health professionals and health services to grow; and, (b) effective stakeholder relationships are a reflection of its participants, team practices and participant contribution to the team, each a positive aspect to the stakeholder relationship.
A holistic approach to health care provision that is ‘undertaken consciously and appropriately, including key stakeholders’ (Quixley 2009) will greatly contribute to quality in service provision for consumers.
There are many arguments that support an inclusive approach that promotes stakeholder participation to service delivery in health. The wellbeing of our community depends on community care health services identifying challenges and developing strategies that maintain and improve stakeholder relationships.
Key principles, those vital to collaborative practice, principles that reflect respectful communication, teamwork, roles and responsibilities, commitment to goals and mission, decentralised power and critical reflection when adopted are strategies that all contribute to continued collaboration and equity among all stakeholders.
Partnerships between stakeholders can ‘facilitate the ongoing development of their sector and assist further development of the sector to a more effective and integrated, outcomes focused and efficient service system (Quixley 2009)’.
Primary health care partnerships provide a forum for health professionals and the health services they represent to work together and achieve reforms in health generally.
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