HEALTHCARE MANAGEMENT zyxwvutsrqponm FORUM GESTION DES SOINS DE SANT~ zyxwv - ORIGINAL ARTICLE zyxwvutsrq Delivery Systems: eeting Accountability by Peggy Leatt and Sandra G. Leggatt Abstract Many Canadian provincial govern- ments are exploring methods to increase the integration of health services in an effort care provided, while lores the issues overnance models is , and the factors that model for an integrated tem are presented. In any Canadian provincial governments are exploring M methods to increase the integration of health services in an effort to the care provided, while maintaining cing the costs.’ Integrated health ry systems have been implemented in the United States, Britain and other European countries.2 Such systems aim to provide a full continuum of care to a defined target popula- ation under a financing system of capitation. In contrast to some other countries, the Canadian public owns the majority of its health care system. Through the tax structure, provincial governments establish mechanisms for the delivery of defined health care ser- vices to the population. Governance of the health care system is the “exercise of author- ity by a group of individuals who are respon- sible and accountable for the direction and control of the 235) and “fulfillment of responsible ownership on behalf of the ~ommunity.”~(P 484) One of the early decisions in the development of an IDS is defining who will carry this responsibility and accountabil- ity on behalf of the owners; in this case, the Canadian public. In the Canadian system, it is usually a board of trustees or directors - in “trust” for the community served - that is accountable for the actions of a health sys- tem. The board’s “job” is to govern on behalf of the defined citizen^.^ Canadian hospitals and other health care organizations have a long history of excel- lence in the voluntary service of citizens in policy making and direction of service delivery. While Ewe11 identified the boards as the weakest link in the integrated health care systems of the United States,6 Umbdenstock et al. stated that, “The volunteer board model has worked very well, and it only needs to be adapted to the changed en~ironment.”~ Early attention to governance in the development of IDS models in Canada may improve the effec- tiveness of these systems. Governance Models for integrated Delivery Systems The models of governance most commonly found in IDSs are the consortium, parent holding, and corporate models. Each is described below. The corporate model implies vertical financial ownership; the con- sortium generally functions with separate ownership; and there are a variety of models in between, with various combinations of ownership. Consortium Model As illustrated in figure 1, the consortium model operates with a centralized umbrella governing body that integrates the service delivery of the component organizations. In this model, each of the components maintains its corporate ownership and identity. The consortium can influence policy and strategic direction for member organizations, but typi- cally does not affect management. In the United States, the consortium model is not common. A 1983 survey of U.S. multi- hospital systems found that only four percent were structured according to a consortium WINTER 1997, VOL. 10, NO. 4 HIVER 1997, VOL. 10, NO. 4