Media reports about health care tend to focus on the problems of managed care and reductions in Medicare, but perhaps the most important story is the one that gets less press. It is a story about the fundamental reorganization of how health care services will be delivered in the future. It is a story about integrating all services—from primary care to surgery to home care to medical transportation—under the ownership of a single company. Numerous researchers and commentators note the rapid pace at which hospitals are merging, consolidating, or developing alliances with other hospitals, physician management companies, and physician practices. Yet there are few tried and true models for how to successfully develop integrated delivery systems. Increasingly these newly formed affiliations and integration activities are breaking down. Recent studies show that many mergers and acquisitions involving different types of health care systems and hospitals are unsuccessful. These relationships often break down over value conflict, particularly those involving faith-based and non faith-based providers. Too often these relationships fail after substantial financial resources have been invested in strategic planning and organizational development.

Studies of the process of integration indicate that failure to align culture and manage values are important operational barriers to achieving successful integration. Recent telephone interviews with approximately 30 health system leaders (conducted by MMI Companies, Inc., an international health care risk management company based in Deerfield, Illinois, and the Park Ridge Center) suggest that while many health system leaders are struggling to identify adequate compensation vehicles to share financial risk with physicians, they also must balance economics with the imperative to ensure high quality care and do so being faithful to their organization's values. Although some health systems are beginning to develop approaches to managing these issues, most are in search of tools, models, and strategies to help define, measure, and manage value differences.

In 1998, MMI and the Park Ridge Center began a collaborative effort to study competing value systems in health care delivery. An important aim of this project is to enhance our understanding of how conflict over competing sets of values at different clinical and administrative levels within integrated delivery systems affects the quality of patient care. Both MMI and the Park Ridge Center believe that unmanaged value conflict and cultural differences will limit health systems' performance and capacity to delivery high quality care. Moreover, we believe that the locus of value conflict can occur between and among many different levels of health system activity. This includes conflict among governing board members, senior clinical and administrative leaders, patient care providers, and patients and their families, as well as members of communities served by health systems.

Through June 1999, this team will conduct comparative case studies of approximately six to ten health care systems in different locations across the United States to learn how health systems are addressing value conflicts. Data collection activities will include leading on-site, key informant interviews and focus group sessions with approximately ten to twelve representatives of each system. The interviews and focus groups will provide opportunities to:

• Delineate key sets of values operating at different levels between and among integrated delivery systems and the approaches utilized to align values
• Identify sources of potential conflict as well as the formal and informal approaches in place to resolve value conflicts
• Explore factors related to the process of integration that may create barriers or help facilitate the resolution of value conflicts
• Illuminate "better practices" in place for describing, measuring, monitoring, and managing values

This is the first collaborative project between the Park Ridge Center and MMI. Both organizations believe that the learning we gain about different health system's approaches to managing values will be of interest to health policy makers and managers. As the nation continues to focus on the market to help stimulate competition for scarce public and private dollars and to improve providers' performance, key issues of values and value conflicts will continue to emerge as an important concern.