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Table 2 Results from thematic analysis of open comments

From: A cognitive perspective on health systems integration: results of a Canadian Delphi study

Main themes Modifications made Comments
Round One Round One Round One
Clarify the: Provided a three-page overview to explain: We retained the term “mental model” for two reasons: (a) no other term conveys the intended meaning and (b) the term maintains the link between this work and the literature on mental models.
• Purpose of the framework • The value of a cognitive perspective on integration  
• Structure of the framework, particularly the section on beliefs/perceptions • The broad meaning of the term “shared”
  • What the framework aims, and does not aim, to do
• Practical applications of the framework • How the framework may be used, including examples In the original framework, the beliefs/perceptions mental model consisted of the same contents as in the knowledge category, but with a focus on “what should be” or “what is perceived or expected”. For example, “clients” can be viewed in terms of which populations are being targeted for integrated care (knowledge of the integration strategy) versus which populations should be targeted (personal belief/perception). Repetition of the content areas created confusion and the contents failed to capture important beliefs/perceptions. Respondents also noted that their way of thinking about integration was complex and dynamic, incorporating knowledge, beliefs and perceptions; they therefore did not view beliefs/perceptions as a separate mental model.
• Terms and definitions in some parts of the framework, including the terms “mental model” and “shared” Replaced the term “Mental Models of Integration” with “Integration Mindset”  
• Patient/caregiver perspective and role Removed “belief/perceptions” as a separate type of mental model and added it as a component to the two remaining mental model types
Include additional content, particularly in the area of beliefs/perceptions Developed additional content to include in the framework, primarily on beliefs/perceptions:
  • Strategy: “evaluation” added as a knowledge component and four beliefs/perceptions added
  • Roles: four beliefs/perceptions added
  Edited several terms and definitions in the framework for clarity and comprehensiveness. For example: Additional framework contents identified through respondent comments and literature.
• Strategy: “services to be integrated” changed to “targets”; “external customers changed to “clients”; and “processes” changed to “methods”  
• Strategy: the definition for knowledge of clients was changed from “patients/caregivers who will benefit from integration” to “characteristics and needs of the populations, patients and/or caregivers who will benefit from integration, and the nature of that benefit”  
• Roles: “knowledge and skills” changed to “competencies”; “role recognition” changed to “accountabilities”; and “interaction mechanisms” changed to “communication”. Minor modifications were made to the definitions for these terms as well (i.e. “role recognition: the purpose and responsibilities of each professional, organization and client” was replaced with “accountabilities: the activities and results that team members are individually or jointly responsible for”).  
Round Two Round Two Round Two
Reduce the number of content areas to improve clarity and reduce overlap Replaced the term “Roles Mental Model” with “Relationships Mental Model” Reducing the number of content areas may be premature without further research.
  Applied minor edits to some terms and definitions. For example:  
Further clarify some terms and definitions in the framework • Strategy: “aptitude for change” changed to “readiness for change” Several respondents noted that the term “role” focused attention on individual professionals and emphasized boundaries.
Further explain why factors such as culture and leadership are not included in the framework • Relationships: we originally described the content for “each participating professional” and “each unit”, the latter defined as a program, department or organization. To improve clarity we now describe each content area using inter-professional and inter-organizational “team members” as the referent point. The next stage of this research aims to develop a measurement tool for capturing and comparing Integration Mindsets as well as practitioner tools.
Develop an assessment tool or checklist to facilitate application • Relationships: “recognition of shared responsibility: willingness to go beyond what one is obliged to do to support or contribute to the integration process” was replaced with “recognition of shared responsibility: a willingness to share the burden of work and act as a team to contribute to the integration process and/or to the delivery of integrated care”  
  Updated the three-page overview with an explanation of the range of contextual factors that influence (but are not inherently a part of) Integration Mindsets