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Relational Coordination in Healthcare: Transforming Relationships for High Performance Jody Hoffer Gittell Professor, Brandeis University, Heller School.

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Presentation on theme: "Relational Coordination in Healthcare: Transforming Relationships for High Performance Jody Hoffer Gittell Professor, Brandeis University, Heller School."— Presentation transcript:

1 Relational Coordination in Healthcare: Transforming Relationships for High Performance Jody Hoffer Gittell Professor, Brandeis University, Heller School for Social Policy & Management Director, Relational Coordination Research Collaborative Massachusetts State Dept. of Health Care Finance and Policy June 30, 2011

2 n Get the rewards and incentives right o need to reward providers for coordination o not for using bargaining power to drive costs up n Build organizational capacity o high quality communication and relationships o supported by formal structures What is needed for coordinated care?

3 n What is relational coordination? n Impact of relational coordination on o quality and efficiency of care o patient and provider well-being n Structures that support relational coordination n Building relational coordination at multiple levels o patient coproduction o patient-centered medical homes o accountable care organizations Agenda

4 Operations Agents Pilots Flight Attendants Mechanics Caterers Cabin Cleaners Gate Agents Ticket Agents Ramp Agents Baggage Agents Fuelers Freight Agents Flight Departure Process: A Coordination Challenge Passengers

5 Here you dont communicate. And sometimes you end up not knowing things…On the gates I cant tell you the number of times you get the wrong information from operations…The hardest thing at the gate when flights are delayed is to get information. AMR: Frequent and timely communication

6 Here theres constant communication between customer service and the ramp. When planes have to be switched and bags must be moved, customer service will advise the ramp directly or through operations…Operations keeps everyone informed. It happens smoothly. SWA: Frequent and timely communication

7 If you ask anyone here, whats the last thing you think of when theres a problem, I bet your bottom dollar its the customer. And these are guys who work hard everyday. But theyre thinking, how do I stay out of trouble? AMR: Problem solving

8 We figure out the cause of the delay. We dont necessarily chastise, though sometimes that comes into play. Its a matter of working together. Figuring out what we can learn. Not finger-pointing. SWA: Problem solving

9 Ninety percent of the ramp employees dont care what happens. Even if the walls fall down, as long as they get their check. AMR: Shared goals

10 Ive never seen so many people work so hard to do one thing. You see people checking their watches to get the on-time departure. People work real hard. Then its over and youre back on time. SWA: Shared goals

11 Employees revealed little awareness of the overall process. They typically explained their own set of tasks without reference to the overall process of flight departures. AMR: Shared knowledge

12 Employees had relatively clear mental models of the overall process -- an understanding of the links between their own jobs and the jobs of their counterparts in other functions. Rather than just knowing what to do, they knew why, based on shared knowledge of how the process worked. SWA: Shared knowledge

13 Site 1: Mutual Respect There are employees working here who think theyre better than other employees. Gate and ticket agents think theyre better than the ramp. The ramp think theyre better than cabin cleaners -- think its a sissy, womans job. Then the cabin cleaners look down on the building cleaners. The mechanics think the ramp are a bunch of luggage handlers. AMR: Mutual respect

14 Site 2: Mutual Respect No one takes the job of another person for granted. The skycap is just as critical as the pilot. You can always count on the next guy standing there. No one department is any more important than another. SWA: Mutual respect

15 Relationships shape the communication through which coordination occurs... Findings

16 For better... Shared goals Shared knowledge Mutual respect Frequent communication Timely communication Problem-solving communication

17 … Or worse Functional goals Specialized knowledge Lack of respect Infrequent communication Delayed communication Finger-pointing

18 This process is called Communicating and relating for the purpose of task integration

19 Investigated performance effects of relational coordination n Nine site study of flight departures over 12 months of operation at Southwest, American, Continental and United n Measured relational coordination among pilots, flight attendants, gate agents, ticket agents, baggage agents, ramp agents, freight agents, mechanics, cabin cleaners, fuelers, caterers and operations agents n Measured quality and efficiency performance, adjusting for product differences

20 Relational coordination and flight departure performance Efficiency Quality Gate time/ flight Staff time/ passenger Customer complaints Lost bags Late arrivals Relational coordination -.21***-.42***-.64***-.31*-.50** Flights/day-.19****-.37***-.30***.13-.22+ Flight length, passengers, cargo.79***.45***.13.12-.54** Passenger connections.12**.19**.09.13.00 R squared.

21 Relational coordination and flight departure performance Relational coordination Quality/efficiency performance index AMR2 AMR1 UNI2 UNI1 CON1UNI3 CON2 SWA2 SWA1

22 Does relational coordination matter in other industries?

23 Case Managers Nurses Attending Physicians Physical Therapists Nursing Assistants Social Workers Technicians Referring Physicians Residents Patient Care: A Coordination Challenge Patients

24 Institute of Medicine report The current system shows too little cooperation and teamwork. Instead, each discipline and type of organization tends to defend its authority at the expense of the total systems function. (2003)

25 Physicians recognize the problem The communication line just wasnt there. We thought it was, but it wasnt. We talk to nurses every day but we arent really communicating.

26 Nurses observe the same problem Miscommunication between the physician and the nurse is common because so many things are happening so quickly. But because patients are in and out so quickly, its even more important to communicate well.

27 Same study conducted in hospital setting n Nine hospital study of 893 surgical patients n Measured relational coordination among doctors, nurses, physical therapists, social workers and case managers n Measured quality and efficiency performance, adjusting for patient differences

28 Relational coordination and surgical performance Length of stay Patient satisfaction Freedom from pain Mobility Relational coordination -.33***.26***.08*.06+ Patient age. Comorbidities.09*.07.01.04 Pre-op status.03.01.20***.28*** Surgical volume.11**.10*.06+.03 R Squared. Observations are patients (n=878) in hospitals (n=9). Model also included gender, marital status, psychological well-being and race. Standardized coefficients are shown.

29 Relational coordination and surgical performance Relational coordination Quality/efficiency performance index Hosp2 Hosp1 Hosp7 Hosp3 Hosp9 Hosp5 Hosp6 Hosp8 Hosp4

30 Relational coordination shifts out the quality/efficiency frontier Quality Efficiency Relational coordination

31 Findings extended to other healthcare settings Medical care units in Boston suburban hospital Medical, surgical and intensive care units in Pennsylvania rural hospitals Chronic care in Boston low income community health centers Chronic care in California multi-specialty group Nursing homes in Massachusetts

32 Relational coordination also improves worker outcomes Increases job satisfaction Increases career satisfaction Increases professional efficacy Reduces emotional exhaustion

33 There are other useful responses to coordination challenges… Reengineering Total quality management Lean strategies Redesigning work flows

34 Addressing technical issues is necessary but not sufficient Weve been doing process improvement for several years, and we think were on the right track. But weve tried a number of tools for process improvement, and they just dont address the relationship issues that are holding us back. -- CMO, Tenet Healthcare Systems

35 Relationships provide the cultural or relational underpinnings for process improvement or lean strategies Why do relationships matter?

36 Relationships of shared goals, shared knowledge and mutual respect enable participants to connect in a meaningful way across functional and organizational boundaries -- allowing them to coordinate on the fly Why do relationships matter?

37 n Shared goals help participants to align their actions with each other n Shared knowledge enables participants to understand how their tasks fit together n Mutual respect encourages participants to value the contributions of others, to consider the impact of their actions on others, and to hear what others have said n Together they reinforce frequent, timely, accurate, problem-solving communication

38 Task interdependence that is reciprocal rather than sequential Uncertainty due to v ariability in the environment, in the inputs themselves, or in patterns of demand Time constraints due to t ime-sensitive customer needs, and/or resource pressures When does relational coordination matter most?

39 Why? n Interdependence, uncertainty and time constraints –Increase information processing needs –Increase stress n Relationships –Increase information processing capacity –Increase social support

40 Does relational coordination matter in your work setting? Examples where relational coordination worked well? Where it worked poorly? Root causes of these differences? Impact on performance?

41 How do organizations support or undermine relational coordination?

42 Invest in frontline leadership Resolve conflicts proactively Reward team performance Select for teamwork Measure team performance Make job boundaries flexible Create boundary spanners Develop shared protocols Develop shared info systems Partner with suppliers Relational Coordination Relationships Shared goals Shared knowledge Mutual respect Communication Frequent Timely Accurate Problem-solving Quality Performance Efficiency Performance Broaden participation in team meetings Organizational structures that support relational coordination Job Satisfaction

43 Here technical expertise exceeds teamwork ability as a criterion; doctors expect teamwork of others simply by virtue of the fact that they are doctors, after all. Select for teamwork

44 Youve got to be a nice person to work here…We pick it up through their references. The doctors here are also sure to know someone who knows that doctor..... Nurses like it here because physicians respect their input. Select for teamwork

45 Teamwork with nurses is always important were always dealing with them. So is teamwork with physicians. We need to know if the physical therapist has an attitude toward physicians because it is so important to communicate with the doctors. Select for teamwork

46 You can be the best social worker in the world, but if you cant work with the other disciplines, then you cant work here. Some are very good diagnostically. But its the communication skills [we are looking for]. Select for teamwork

47 The quality assurance (QA) committee is strictly departmental and its strictly reactive. Everybody is giving reports to QA but nobody is listening or learning. The QA committee satisfies hospital-wide reporting requirements. But its not effective. We have board members on that committee, but we still cant get it to work. People have a bad attitude when they go. Its a lengthy, cumbersome meeting. Measure team performance

48 Quality assurance used to be completely reactive here, with incident reports. There would be a review to determine injury or no injury. QA is more real-time now, not so reactive. But we dont have a full system in place. Its evolving… Its not cross-functional yet. Usually I take the nurses and the chief of the service takes the physicians. There is finger-pointing. Measure team performance

49 We have a history of punitive measures. Now itswhat makes competent people fail? What in the system failed? What piece of information was missing? We are looking at a learning perspective now. Its still a QA function. But now its more like quality improvement. Measure team performance

50 We have a Bone Team which includes the service line director, the case management supervisor, the head of rehab, the VP for nursing, the nurse manager, the clinical specialist, three social workers and three case managers. We generally look at system problems. Measure team performance

51 I would say that for any non-physician to challenge a physician has the whole episode laced with pitfalls. For a nurse, a therapist, a pharmacist, a social worker, a nutritionist, an occupational therapist to challenge a physician is up there with losing a job or getting a divorcevery stressful. And I can say personally as a nurse that in my more formative years that was something that you would try to avoid at all costs. Resolve conflicts proactively

52 The kinds of conflicts we often have are disagreements about the patients treatment plan: what it should be. It can go across all of the groups. The other big thing is getting a physician to come up to the unit, to be available.... We have a formal grievance process if youre fired, but not for conflicts among clinicians.... There are no particular processes. We just hope people use common sense and talk to each other. - Resolve conflicts proactively

53 We have a physician relations committee, which deals with conflicts between the hospital personnel and the doctors and sometimes deals with doctor-doctor conflicts. There is a surgical relations committee that deals with specific incidents that occur in the OR (like, for instance, when a doc is abusive to a nurse or another doc in the OR). Each of these committees has about seven members: one nurse, one administrator, and the rest are mostly doctors and allied health professionals. Resolve conflicts proactively

54 We have a staff council thats largely responsible for information sharing among the departments. The staff council deals with medical policy and conflict resolution.... Its an informal body to air differences. Its more for problem solving. We have monthly meetings that are attended by all medical staff, including physicians, nursing, and social work. Resolve conflicts proactively

55 We implemented training classes for all employees that teach employees how to deal with conflict resolution, including adopting appropriate behaviors. There is a Pledge to My Peers, which is a structured format for resolving conflicts in a peer-to-peer fashion. Aggrieved employees are encouraged to approach the coworker or supervisor or whoever and say, I would like to speak with you regarding the pledge. Resolve conflicts proactively

56 There are certain cultural tendencies that inhibit others from doing their work. Therapists train nurses in mobility, but still nurses are often reluctant to deal with moving the patient, getting the patient out of bed, etc. Its partly because they feel they arent qualified, and partly because thats just considered a PT thing. Make job boundaries flexible

57 There are customs – like the fact that a physical therapist will never deal with bedpans and such – that go above and beyond licensing. These customs have a negative effect, like when a physical therapist will go get a nurse just to deal with the bedpan, making things difficult. Make job boundaries flexible

58 [Here] physical therapists definitely do the bedpans. You see, length of stay is so compressed and time is so valuable. Youll only delay yourself if you try to hunt down the nurses aide. Make job boundaries flexible

59 Its a question of what youd rather defend. That you did nothing, or that you tried to help, even if you may have gone beyond your licensing. I tell my nurses Id rather defend them doing too much than not enough. Make job boundaries flexible

60 I can spend half of my day tracking down patients. I will hear somebody mention somewhere in the hallway about a patient with this condition, and theyre not on my printout, so Ive got to walk on every floor and say, Do you have this patient? And they go: Oh that patients on the vascular service, but yeah, I think Dr. So and So already operated on him. Its ridiculous. Develop shared information systems

61 You cant track down all of the physicians here because some of the physicians have their own system. Thats a problem – they dont talk. Independent physicians have their own independent systems, and they only talk to themselves. I mean, so theres a big problem. Some of them are on the email system, and some of them arent. Develop shared information systems

62 Information systems are important for coordination, I think, but right now they are more a hope than a reality. Our chief information officer is building a clinical and administration information system allowing patients to receive care anywhere across the continuum…For automation to work, its important to get a format thats understood across specialists. Develop shared information systems

63 In some cases, its added time for order entry, but the additional time has been outweighed by far less aggravation in trying to locate a record….People recognize the power of having a system like provider order entry because you can do incredible medical management just by providing information at the point of care. Develop shared information systems

64 Weve been so successful with data entry that we cant keep up the demand from our providers. There are probably about 55 things that people currently want to change to our current application. We put together an order entry advisory committee, a group of physicians and nurses that come together on a monthly basis, and they prioritize whats the most important thing on the list now that we need to do. Develop shared information systems

65 Invest in frontline leadership Resolve conflicts proactively Reward team performance Select for teamwork Measure team performance Make job boundaries flexible Create boundary spanners Develop shared protocols Develop shared info systems Partner with suppliers Relational Coordination Relationships Shared goals Shared knowledge Mutual respect Communication Frequent Timely Accurate Problem-solving Quality Performance Efficiency Performance Broaden participation in team meetings Organizational practices that support relational coordination Job Satisfaction.44***.26***.33***.17**

66 Case Managers Nurses Attending Physicians Physical Therapists Nursing Assistants Social Workers Technicians Referring Physicians Residents Organizational practices can connect care providers AROUND the patient Patient

67 Relational coordination works at multiple levels Micro-micro (patient co-production) Strengthen RC between patients and care providers Micro (patient-centered medical home) Strengthen RC between care providers in same micro-system Macro (accountable care organization) Strengthen RC between care providers across micro-systems



70 Getting from here to there

71 Measuring relational coordination RC dimensionsSurvey questions 1. Frequent communication How frequently do people in each of these groups communicate with you about [focal work process]? 2. Timely communication How timely is their communication with you about [focal work process]? 3. Accurate communication How accurate is their communication with you about [focal work process]? 4. Problem solving communication When there is a problem in [focal work process], do people in these groups blame others or try to solve the problem? 5. Shared goalsHow much do people in these groups share your goals for [focal work process]? 6. Shared knowledge How much do people in these groups know about the work you do with [focal work process]? 7. Mutual respectHow much do people in these groups respect the work you do with [focal work process]?

72 A B E D C Mapping relational coordination

73 Physicians 3.70 Day nurses 4.42 Nurse mgrs 4.57 Secretaries 4.57 Night nurses 4.43 Mapping relational coordination in a neonatology practice 3.23 3.95 4.24 4.26 3.72 3.78 3.67 3.71 3.97 4.36

74 Consultant was asked to help n Physicians considered to be a problem n Uncivil behaviors among themselves and with other groups n Consultant focused on physicians, using –Appreciative inquiry –New physician group leader –Coaching and goal-setting –Accountability for relational behaviors –Established weekly meetings to check in, make group decisions

75 4.22 Day nurses 4.30 Nurse mgrs 4.17 Secretaries 4.14 Night nurses 4.39 Mapping relational coordination after six month intervention 3.55 3.92 4.12 4.06 4.07 3.50 3.92 3.87 4.16 3.99 Shaded numbers indicate significant positive change Physicians

76 Only partial success n Relational coordination improved –Among physicians –Between physicians and nurse managers –Between nurse managers and secretaries n But RC stayed the same or got worse –Between other groups nShared knowledge did not improve for anyone, even physicians n Lessons we can learn?

77 Lessons learned n Focus on physicians overlooked other groups –Intervention should include all groups to build shared goals, shared knowledge, mutual respect more broadly n Focus on physicians ignored work process –Intervention should include process improvement (lean, PDSA, TQM) to improve relational dynamics in the context of improving the work

78 Step 1: Measure and map relational coordination Identify work process needing improvement Identify work groups in that process, including client Identify and measure key performance outcomes Measure RC among all work groups, map network Identify strong and weak ties Discuss root cause of variations, identify areas for improvement

79 Step 2: Intervene to improve relational coordination Use information from Step 1 Use process improvement tools (lean, PDSA, TQM) to improve work process Use coaching and training to build shared goals, shared knowledge, mutual respect Measure and assess

80 Step 3: Assess and improve organizational practices Assess organizational practices Which ones support RC? Which ones do not? Develop plan of action to redesign as needed

81 Step 4: From micro to macro-system n Involve stakeholders from micro-systems n Share improvements n Assess needs for macro-system improvements

82 Accountable care requires a multi-level approach To achieve both quality and efficiency, accountable care requires coordination at multiple levels Micro-micro Strengthening patient-provider RC for patient co-production Micro-level Strengthening provider-provider RC within micro-systems Macro-level Strengthening provider-provider RC across micro-systems

83 References Havens, D.S., Gittell, J.H., Vasey, J., Lin, W.T. (2010). Relational Coordination Among Nurses and Other Disciplines: Impact on the Quality of Patient Care, Journal of Nursing Management,. Gittell, J.H., Seidner, R.B., Wimbush, J. (2010). A Relational Model of How High Performance Work Systems Work, Organization Science, 21(2). Gittell, J.H. (2009). High Performance Healthcare: Using the Power of Relationships to Achieve Quality, Efficiency and Resilience. New York: McGraw-Hill. Gittell, J.H., Weinberg, D., Bennett, A., Miller, J.A. (2008). Is the Doctor In? Impact of Job Design on Relational Coordination and Performance, Human Resource Management, 47(4). Gittell, J.H. (2008). Relationships and Resilience: Care Provider Responses to Pressures from Managed Care, Journal of Applied Behavioral Science, 44(1). Gittell, J.H., Weinberg, D.B., Pfefferle, S., Bishop, C. (2008). Impact of Relational Coordination on Job Satisfaction and Quality Outcomes: A Study of Nursing Homes, Human Resource Management Journal, 18(2). Weinberg, D.B., Lusenhop, W., Gittell, J.H., Kautz, C. (2007). Coordination between Formal Providers and Informal Caregivers, Health Care Management Review, 32(2). Gittell, J.H., Weiss, L. (2004). Coordination Networks Within and Across Organizations: A Multi-Level Framework, Journal of Management Studies, 41(1). Gittell, J.H. (2003). The Southwest Airlines Way: Using the Power of Relationships to Achieve High Performance. New York: McGraw-Hill. Gittell, J.H. (2002). Coordinating Mechanisms in Care Provider Groups: Relational Coordination as a Mediator and Input Uncertainty as a Moderator of Performance Effects, Management Science, 48(11). Gittell, J.H. (2002). Relationships between Service Providers and their Impact on Customers, Journal of Service Research, 4(4). Gittell, J.H. (2001). Supervisory Span, Relational Coordination and Flight Departure Performance, Organization Science, 12(4). Gittell, J.H., Fairfield, K., et al (2000). Impact of Relational Coordination on Quality of Care, Post-Operative Pain and Functioning, and Length of Stay: A Nine Hospital Study of Surgical Patients, Medical Care, 38(8). Gittell, J.H. (2000). Paradox of Coordination and Control, California Management Review, 42(3). Gittell, J.H. (2000). Organizing Work to Support Relational Coordination, IJHRM, 11(3).

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