relational coordination and patterns in the clinical ... · 1 clinicalmicrosystem.org relational...

2016-03-09

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clinicalmicrosystem.org

Relational Coordination: Patterns in the Clinical Microsystem

Tina Foster MD, MPH, MS

The Dartmouth Institute Microsystem Academy

4 March 2016

Microsystem Festival

Jonkoping, Sweden


The 5 P’s

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Microsystem 5 P’s


• Results – what comes out of our work

• Behaviors – how we do our work

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Patterns

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What is Relational Coordination?

• “a mutually reinforcing process of interaction between communication and relationships carried out for the purpose of task integration”

• Studied in airlines, health care, and other settings using validated RC survey

• “Strength of relational coordination ties among participants in a work process predicts an array of strategically important outcomes including quality and safety, efficiency and financial performance, customer engagement and employee outcomes.”

Gittell , J.H. Journal of Service Research, 4 (4), 299 – 311, 2002 http://rcrc.brandeis.edu/about-rc/Overview%20of%20Relational%20Coordination1.pdf


RC and Performance

Nine Northeast Orthopedic Departments -Gittell et al, Medical Care, 2000

Nine U.S. Airlines -Gittell: The Southwest Airline Way: Using the Power of Relationships to Achieve High Performance, McGraw Hill, 2003

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7 Dimensions of Relational Coordination

Seven RC Dimensions Survey Questions

1. Frequent communication How frequently do people in each of these groups communicate with you about the work that we do together?

2. Timely communication How timely is their communication with you about the work that we do together?

3. Accurate communication How accurate is their communication with you about the work that we do together?

4. Problem solving communication

When there is a problem in the work that we do together, do people in these groups blame others or try to solve the problem?

5. Shared goals Do people in these groups share your goals for the work that we do together?

6. Shared knowledge Do people in these groups know about the work you do in the work that we do together?

7. Mutual respect Do people in these groups respect the work you do in the work that we do together?

5= Always, Completely ; 4= Often, A lot; 3= Occasionally, Somewhat; 2= Rarely, A little; 1= Never, Not at all

Scoring: Between and Within Groups


An Opportunity…

• Leadership interest in relational coordination in D-H surgery department

• Survey already planned…but what to do with results?

• Existing program to develop improvement coaches (eCTC); newer program to further develop communication skills (Tools to Relationships)

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Relational Coordination, Coproduction & Leadership

Shared Goals

Shared Knowledge Mutual Respect

Frequent

Timely Accurate

Problem-Solving Communication

Relational Interventions Psychological Safety

Feedback of RC Metrics Coaching/Humble Inquiry

Structural Interventions Select/Train for Teamwork

Shared Accountability Shared Costs and Rewards

Conflict Resolution Practices Meetings and Huddles

Cross-Boundary Job Design Shared Protocols

Shared Info Systems

Performance Outcomes Quality

Efficiency Citizen Engagement Worker Well-Being

Improvement Methodologies Lean/Six Sigma

Plan/Do/Study/Act Positive Deviance

Relational Model of Organizational Change + Microsystem Academy Gittell, Edmondson, Schein Coach the Coach Program

RC + TDIMA


The Questions

• What can we learn about using the RC survey and results?

• Would improvement work and coaching improve RC?

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Practice Manager

Nurses Surgeons

Coordinators Nursing Assistants

Advanced Practitioners Technologists

Secretaries Residents

Relational Coordination: Relationship Mapping

Patients


Drill Down into Details Workgroup Effects

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Relational Map


Relational Coordination Surgery Department

3,0

3,5

4,0

4,5

Between Within Combined

2014 2015> 4.0 = High

Performance

Groups Groups

> 4.5 = High Performance

5= Always, Completely ; 4= Often, A lot; 3= Occasionally, Somewhat

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3,0

3,5

4,0

4,5

CT Derm Gen Neuro Opth Otol Ped Plast Trans Urol Vasc

Relational Coordination by Section

2014 2015


RC and Satisfaction

• Patient satisfaction associated with RC, especially for initial visit

• Provider engagement and job satisfaction associated with RC

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Some Lessons

• Helpful but hard to keep focus on a specific process and roles

• Preparation

• Time/space/attention matters….

• Learning from each other is powerful

• Quantification attracted people, but in the end it was far less important than the conversations generated

• Ongoing work to develop communication skills embraced

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Technical vs Humanistic

Technical/Mechanical Improvement

Total Quality Management

Lean

Six Sigma

Model for Improvement

Process mapping

Work flow mapping

Data & Measurement

“Humanistic” Considerations

Individual and group dynamics

Communication

Relationships

Human dynamics

Organizational learning

Ownership

Leadership

Patients and families 18 0935-0945

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MESOSYSTEM – SERVICE LINES & CARE PATHWAYS

MICROSYSTEM – FRONT LINES

MACROSYSTEM – ORGANIZATIONS

METASYSTEM – NETWORKS & REGISTRIES

Many Levels Important


Ongoing Work

• OneCF Learning and Leadership Collaboratives

– Practice helps

– Patients and families

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Thanks!

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Relational Model of Organizational Change

22 https://rcrcconnect.org/resource-center/intervention-database/

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3,0

3,5

4,0

4,5

5,0

Frequent Timely Accurate Problem-Solving Shared Goals SharedKnowledge

Mutual Respect

Between Groups 2014 2015

3,0

3,5

4,0

4,5

5,0

Frequent Timely Accurate Problem-Solving Shared Goals SharedKnowledge

Mutual Respect

Within Groups 2014 2015

Relational Coordination 7 Dimensions

Communication

Communication

5= Always, Completely ; 4= Often, A lot; 3= Occasionally, Somewhat


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Team Coaching Model

Pre-Phase Getting Ready

“Meet them where they are”

Action Phase Art & Science of Coaching

Transition Phase Reflection, Celebration &

Renew

*Context -Review of past improvement efforts and lessons learned-tools used -Preliminary system review-Micro/Meso/Macro *Site Visit -Resources -Logistics *Expectations Clarity of aim Leadership & Team discussions about roles and logistics

*Relationships -Helping -Keep on track *Communication -Virtual -Face-to-Face -Available & accessible -Timely *Encouragement *Clarifying - Improvement Knowledge -Expectations *Feedback *Reframing - Different perspectives - Possibility -Group dynamics-new skills *Improvement Technical Skills - Teaching

Reflection on improvement journey -What to keep doing or not do again -Review measured results and gains -Assess team capability and coaching needs & create coaching transition plan Celebration! Renew and re-energize for next improvement focus Evaluate coaching

Godfrey, MM (2013)

relational coordination and patterns in the clinical ... · 1 clinicalmicrosystem.org relational...

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