Developing a Service Quality Standard for Collaborative Integrated Healthcare

Introduction

According to statistics, by the end of 2023, China’s population aged 60 or above had reached 297 million, accounting for 21.1% of the total population, while the population aged 65 or above was 217 million, making up 15.4%. ¹ It is predicted that by 2030, China will become the most aged society globally. Along with the aging process intensifies² and the family care function weakens, the demands for institutional elderly care in China continue to rise.³ As Guangzhou transitioned into an aging society in 1992, in response, the local government has actively developed elderly care services through a series of policy initiatives aimed at reforming the service industry and advancing healthcare integration. “Integrated healthcare”, a new model combining medical, rehabilitation and pension services, is a key initiative to cope with the challenges of aging and promote the equalization of public services. In China, it is also referred to as “the integration of health and social care” or “the combination of medical and elderly care” has become synonymous with complete care for the elderly.⁴

As 2013, the development of integrated healthcare had been incorporated into several key planning documents,⁵ becoming one of China’s primary strategies to address population ageing.⁶ The “Several opinions on further promoting the development of integrated healthcare”,⁷ issued in 2019, clearly advocated for closer integration of healthcare and elderly care services through enhanced contractual cooperation and strengthened information technology infrastructure.⁵ Guided and supported by the policy, localities had actively explored integrated healthcare service modes and gradually developed diverse modes such as “Medical-embedded Elderly Care”, “Care-embedded Medical Services” and “integrated medical-care contract”. By the end of 2023, 87000 pairs of elderly care and medical health institutions had established contractual partnerships nationwide, marking a 3.6% increase from the previous year.⁸ This signifies that the institutional cooperation model of “integrated medical-care contract” has become a key direction for advancing integrated healthcare development in China.

Collaborative cooperation between medical and pension institutions is a key mechanism for advancing the integrated healthcare model and achieve “healthy aging”. Tertiary hospitals, with their high-quality medical resources and regional influence, should serve as leading entities for health management services.⁹ Institutionally collaboration in integrated healthcare is primarily implemented through contract models and entrusted management. This approach promotes two-way referrals and resource integration through a division of labor and cooperation mechanism, led by hospitals and assisted by pension institutions. Institutional cooperation, being a complex model involving multiple stakeholders, is more challenging to implement. Therefore, the specificity and depth of research in this area need to be further developed.¹⁰

However, existing studies primarily focused on micro-level service evaluations of individual institution, with limited exploration of the synergistic roles of medical institutions and collaborative models.Our study was designed around the needs of the elderly, incorporating the concepts of “healthy and active aging”, applied the Structure-Process-Outcome (SPO) model and the Rainbow Model of Integrated Care (RMIC) as conceptual framework, developing a service quality standard for institutional collaborative healthcare based on literature review, field research interviews, Delphi method and the AHP. The goal was to explore the leading role of tertiary hospitals in integrated healthcare services, providing a scientific foundation and practical guidance for improving service qual

Formulation of the Expert Consultation Questionnaire

A literature review method was employed to systematically collect research on service quality standard for healthcare integration institutions. The time frame of the search was 2010/1/1-2024/7/31, Chinese/English literature was included, and duplicated, non-empirical studies were excluded. “long-term care facilities, nursing homes, homes for older people, elderly care institutions, nursing institutions for the elderly”; “institutional cooperation, medical contract, integrated care, medical care combination, healthcare integration”, and “quality evaluation, service quality, quality standard, quality indicator system” were used as the search terms and extracted databases from CNKI, WanFang, VIP, PubMed, Cochrane Libary, Web of Science and Embase. The results of the reviewed literature were organized and analyzed to create a repository of evaluation standard.

Based on the literature review, semi-structured interviews about service benchmarks, gaps and implementation challenges in integrated healthcare were conducted with staff and elderly residents at three institutions in Guangzhou, China. Field investigations and research revealed that no matter what form of medical and elderly care integrated institution it was, the development of integrated healthcare models in China remained underdeveloped. Based on observations from the three surveyed institutions above, it was evident that integrated healthcare services had encountered numerous challenges in their development. Challenges such as misaligned operational philosophies, incomplete regulatory frameworks, shortages of professional talent, outdated infrastructure, and the lack of service evaluation systems had hindered the sustainable improvement of service quality.By synthesizing the findings from literature reviews and qualitative research, a preliminary draft of the service quality standard was formulated.

Implementation of the Expert delphi Round

From August to October 2024,expert consultation questionnaires were distributed via email,followed by two roun

Indicator Screening and Modification

After the first round of correspondence,adjustments were made to the indicators based on the screening criteria and discussions with experts. One second-level indicator was deleted (due to content duplication and a high coefficient of variation), 8 third-level indicators were removed (due to high coefficients of variation), three indicators were added, two were merged, and fourteen were modified, as detailed below: The second-level indicator “Education and training” was eliminated. Among the third-level indicators, three items related to “Free clinic activities”, three items linked to “Education and training”, along with “Organize health and recreational activities” and “Employee resignation rate in pension institutions” were removed.Process indicators “Provide emergency green channels for elderly in pension institutions” and outcome indicators “Operational cost control in pension institutions” and “Medical expenditure control in pension institutions” were included.Following the second round of consultation questionnaire, no modification was proposed by experts for the first or second-level indicators, but 1 third-level indicator was removed (due to its importance mean did not satisfy the inclusion criteria), and six were modified. The final service quality standard for collaborative integrated healthcare institutions consisted of 3 first-level indicators, 14 second-level indicators, and 63 third-level indicators.

The Final Standard System with Indicator weights

In this study,the Saaty scale was resolute by calculating the difference in mean importance scores from the second round of the Delphi method. Such as, a mean difference in importance scores ranging from 0.25 to 0.5 corresponded to a Saaty scale of 3, while ranging from −0.5 to −0.25 corresponded to 1/3; which formed a three-layer hierarchical model, including the target, guideline and scheme layer. Then the model and judgement matrix were inputted into the Spssau software to derive the weights of each index. The CR value for the first-level indicator was 0.052 (<0.1).While the CR values for the second-level indicators of structure, process, and outcome were 0.008, 0.019, and 0.027 respectively (all <0.1). the effect on institutionally collaborative integrated healthcare services, ranked from largest to smallest, was service process (0.493), service structure (0.311) and service outcome (0.196). The combined weights of the second-level indicators were 0.021-0.181, among which institutional processes and human resources had the greatest impact on service structure, the operational management of integrated healthcare services exerted the most significant influence on service process, and elderly in pension institutions contributed most to service outcomes. The combined weights of the third-level indicators were 0.002-0.066, with the establishment of a professional service team for integrated healthcare in tertiary hospi

“Human resources” and “Institutional processes” receive maximal weighting in structure indicators which is consistent with the findings of Pan AH²¹ and Zhu L.²² Thus, integrated care requires strong safety systems for dependent elderly and optimal staffing to ensure effective service delivery and maximize benefits.²³ Simultaneously occurring, Operational management metrics scores the highest weight value in process indicators, which enhances service quality, efficiency, and coordination in integrated healthcare institutions to ensure standardized delivery and optimal resource utilization. The structural quality indicators provide a material foundational basis for service delivery, and the process quality indicators emphasizes the entire process, guaranteeing the implementation of service measures.Ultimately,outcome quality indicators employee multi-dimensional quantitative measures to comprehensively assess the content,quality,efficiency and accessibility from the outlook of user satisfaction,^24,25 offering a scientific basis for evaluating goal attainment.

building on China’s existing policy initiatives, including long-term care insurance pilots and integrated elderly healthcare programs,²⁶ the establishment of evidence-based quality standards for collaborative integrated healthcare institutions has become a critical next step.These scientifically grounded standards serve three key policy objectives: Protecting elderly residents’ safety and rights through standardized care protocols, optimizing the allocation of high-quality medical resources across institutions and supporting the hierarchical medical care system through measurable performance benchmarks. To ensure policy alignment and implementation, we propose incorporating these standards into Guangdong Province’s medical institution grading system, where they could inform both quality assessment frameworks and health insurance payment reform parameters.

Strengths and Limitations

Drawing on literature research and field investigations,this study enriches the evaluation standard for the service quality of collaborative integrated healthcare institutions by examining service organizational structure,delivery processes and outcomes,demonstrating its significant value in service optimization,resource integration,cost control,rights protection and industry development. Compared to community-based integration models in Western countries, this study focuses on tertiary hospital-led healthcare integration with Chinese characteristics, filling the gap of localized service quality standards.However, the following limitations also exist: First, as the invited experts are mainly from Guangdong province, the standard system is more applicable to cities or regions with similar healthcare systems, which restricts the universality of the results to other areas. For instance,in rural China,some structural indicators may need to be modified. Second, the quality standard identified in the study have not yet been verified for reliability, validity or feasibility by multiple institutions. Verification and testing are necessary before the standard can be widely implemented. The research team will subsequently test the practicality of the standard in practice, continuously revising and improving the standards to ensure that integrated healthcare institutions can consistently deliver high-quality care services.

Conclusion

The development of integrated healthcare services is essential for addressing health governance challenges associated with aging while also driving structural reforms in elderly care service supply, making it a key component of the Healthy China strategy. Thus,studying its development trajectory is highly significant. Through two rounds of Delphi expert consultation, this study has developed a se

8. china National Committee on ageing. Bulletin on the development of the national aging program in 2023. 2025. Available from: https://www.cncaprc.gov.cn/llxw/194437. Accessed October 11, 2024.
9. Zhu PH. Study on Health Management Service Capability Evaluation and Model Optimization of Guangxi Tertiary General Hospital Under the Framework of Hospital United System. Guangxi Med Univ; 2019.
10. Chen YL. Research on the development dilemma and resolution of institutional-based integration of medical care and elderly care. Univ Electron Sci Tech.2023.
11. Guo WL, Zhao CY, Huang ZC, et al. Researches on the construction of internet hospitals based on SPO model. Chin Health Serv Manag. 2021;38(8):570-573.
12. Valentijn PP, Schepman SM, Opheij W, et al. Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. Int J Integr Care. 2013;13(1):e010. doi:10.5334/ijic.886.
13. Zhang HF, Feng ZX, Shao LW, et al.Study on nursing-sensitive quality indicators on the basis of evidence-based medicine. Chin J Nurs. 2015;50(3):287-291.
14. Okoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Inform & Manag. 2004;42(1):15-29. doi:10.1016/j.im.2003.11.002.
15. Zhou WQ, Liu Y, Liu LS, et al. Research advances and insights on the rainbow model of integrated care. Chin J Nurs.2024;59(4):496-501.
16. Saaty RW. The