Relational Coordination

Relational Coordination in
Theory and Practice
Social Impact
University College South Denmark
April 28, 2016
Jody Hoffer Gittell
Professor, Brandeis University
Director, Relational Coordination Research Collaborative
Challenges we face
Pressure to transform social services
Achieve better outcomes for our citizens
 And do it more efficiently
Doing more with fewer resources
Is this even possible?
Today
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What is relational coordination? How does it
impact performance?
Is it relevant for your work?
How do our organizations support it – or not?
Getting from here to here – a relational model
of organizational change
Three case studies
Operations
Agents
Flight departure process:
A coordination challenge
Ramp
Agents
Baggage
Agents
Gate
Agents
Ticket
Agents
Cabin
Cleaners
Caterers
Passengers
Freight
Agents
Fuelers
Flight
Attendants
Mechanics
Pilots
American: Frequent and
timely communication
“Here you don’t communicate. And
sometimes you end up not knowing
things…On the gates I can’t 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.”
Southwest: Frequent and
timely communication
“Here there’s 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.”
American: Problem solving
communication
“If you ask anyone here, what’s the last thing
you think of when there’s a problem, I bet
your bottom dollar it’s the customer. And
these are guys who work hard everyday. But
they’re thinking, how do I stay out of
trouble?”
Southwest: Problem solving
communication
“We figure out the cause of the delay. We
don’t necessarily chastise, though sometimes
that comes into play. It’s a matter of working
together. Figuring out what we can learn.
Not finger-pointing.”
American: Shared goals
“Ninety percent of the ramp employees don’t
care what happens, even if the walls fall down,
as long as they get their check.”
Southwest: Shared goals
“I’ve 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 it’s
over and you’re back on time.”
American: Shared knowledge
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.
Southwest: Shared knowledge
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.
American:
Mutual
respect
Site 1: Mutual
Respect
“There are employees working here who
think they’re better than other employees.
Gate and ticket agents think they’re better
than the ramp. The ramp think they’re better
than cabin cleaners -- think it’s a sissy,
woman’s job. Then the cabin cleaners look
down on the building cleaners. The
mechanics think the ramp are a bunch of
luggage handlers.”
Site
2:
Mutual
Respect
Southwest: 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.”
Findings
Relationships shape the
communication through which
coordination occurs ...
For better...
Shared goals
Frequent
Shared knowledge
Timely
Mutual respect
Accurate
Problem-solving
communication
… or worse
Functional goals
Infrequent
Specialized
knowledge
Delayed
Lack of respect
“Finger-pointing”
communication
Inaccurate
This process is called
“Communicating and relating
for the purpose of task integration”
Does relational coordination
matter for performance?
Investigated performance effects
of relational coordination
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Nine site study of flight departures over 12
months of operation at Southwest, American,
Continental and United
Measured quality and efficiency performance,
adjusting for product differences
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
Survey questions
RC dimensions
Survey 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 goals
Do people in these groups share your goals for [focal
work process]?
6. Shared
knowledge
Do people in these groups know about the work you
do with [focal work process]?
7. Mutual respect
Do people in these groups respect the work you do
with [focal work process]?
Relational coordination drives
flight departure performance
SWA1
CON2
SWA2
Quality/efficiency
performance
index
CON1
UNI1
AMR1
AMR2
UNI2
Relational coordination
UNI3
Case
Managers
Patient care:
A coordination challenge
Attending
Physicians
Nurses
Physical
Therapists
Nursing
Assistants
Patients
Social
Workers
Technicians
Referring
Physicians
Administrators
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
system’s function.” (2003)
Physicians recognize the problem
“The communication line just wasn’t there.
We thought it was, but it wasn’t. We talk to
nurses every day but we aren’t really
communicating.”
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, it’s even
more important to communicate well.”
Same study conducted in
hospital setting
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Nine hospital study of 893 surgical patients
Measured quality and efficiency
performance -- and job satisfaction,
adjusting for patient differences
Measured relational coordination among
doctors, nurses, physical therapists, social
workers and case managers
Relational coordination drives
surgical performance
Hosp6
Hosp4
Hosp8
Quality/efficiency
performance index
Hosp9
Hosp3
Hosp7
Hosp1
Hosp2
Relational coordination
Hosp5
Nursing
Aides
Elder care:
A coordination challenge
Activities
Staff
Nurses
Dietary
Staff
Therapists
Resident
and family
Housekeeping
Staff
Case Managers
Referring
Physicians
Attending
Physicians
Coordination is lacking
“The problem is that doctors in acute care don’t
understand what happens in long-term care or
rehab. …In post-acute there’s a knowledge gap
about what is going on in acute care. There
often aren’t very good processes in place, so
patient transitions can be very ad hoc…”
Families recognize the problem
“I’m in Arizona, my mother is in Florida, and I’m
working long distance to orchestrate home care.
There were all sorts of scheduling mix-ups and
miscommunication. The doctor’s office sent in
the referral for home care, and then closed for
the day. It ended up taking 36 hours to get home
care. Meanwhile my mother—who is very high
risk for a frightening and expensive
hospitalization—was kept waiting.”
Staff see the same problem
“The problem here is that people don’t talk –
and it’s the residents who lose. The nursing aide
knows when a resident is having trouble eating
or mobilizing or is feeling down. But who is
listening? She can’t talk to dietary or activities
or physical therapy. Here everything has to go
through the chain of command.”
Study conducted in nursing homes
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Fifteen nursing home study of 105 residents
Measured relational coordination between
234 nursing aides, nurses, dietary staff and
housekeeping staff
Measured resident quality of life, adverse
events, and staff job satisfaction, adjusting
for resident and staff characteristics
Relational coordination drives
elder care performance
Resident
quality of life
Adverse outcomes
(weight loss, sores,
functional loss, UTIs)
Staff job
satisfaction
Relational coordination
.39**
-.40***
.30***
Resident age
-.13
.04
.04
Resident gender
.19+
-.06
-.01
Resident tenure
.16
-.08
-.04
Resident severity
.61
-1.90+
--
Staff language
.23
-.27***
-.07
R squared (between)
.24
.21
.31
Observations are residents (n=93) and staff (n=234) in long term care facilities
(n=15). Model also included facility size and ownership. Standardized
coefficients are shown.
Relational coordination drives
elder care performance
LTC12
LTC5
LYC14
Performance
index
LTC10
LTC6
LTC4
LTC2
LTC11
LTC8
LTC7
LTC9
LTC3
LTC15
LTC1
Relational coordination
LTC13
Research has continued…
Across multiple sectors…
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Airlines
Banking
Retail sector
Manufacturing
Accounting
Consulting
Early child education
Elementary education
Higher education
Youth services
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Surgical care
Medical care
Emergency care
Intensive care
Obstetric care
Primary care
Chronic care
Home care
Long term care
Pharmacy sector
And in 18 countries…
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United States
Canada
Denmark
Norway
Sweden
Austria
Switzerland
Netherlands
Belgium
Scotland
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England
Ireland
Japan
China
Korea
Pakistan
Israel
Australia
New Zealand
Ecuador
Efficiency & financial outcomes
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Reduced turnaround time
Reduced product development costs
Increased employee productivity
Reduced length of hospital stay
Reduced total cost of hospital care
Reduced inpatient hospitalizations
Reduced total costs of chronic care
Increased profit growth
Increased growth of deposits
Improved operational excellence
Quality & safety outcomes
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Reduced customer complaints
Increased on-time performance
Increased product development quality
Increased patient satisfaction with care
Increased patient psychological well-being
Increased patient intent to recommend
Improved postoperative pain/ functioning
Improved quality of chronic illness care
Increased quality of life for elderly
Reduced medication errors
Reduced hospital acquired infections
Reduced patient fall-related injuries
Client engagement
 Increased trust and confidence in care team
 Increased self-management
 Increased evaluation, enrollment and
retention of drug-exposed infants
 Increased community linkages
 Increased family readiness for caregiving
 Increased family engagement with teachers
 Reduced parenting stress
 Increased ability to care for autistic child
 Increased ability to cope with needs of child
Worker engagement
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Increased job satisfaction
Increased career satisfaction
Increased professional efficacy
Increase competence at work
Reduced burnout
Increased work engagement
Increased involvement at work
Increased proactive work behaviors
Increased motivation at work
Increased equity of contribution
Increased dual allegiance
Learning & innovation
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Increased psychological safety
Increased ability to learn from failures
Increased reciprocal learning
Increased collaborative knowledge creation
Increased innovation
Relational coordination pushes out the
quality/efficiency frontier to increase value
creation
Quality &
Safety
Outcomes
Relational
coordination
Efficiency & Financial Outcomes
There are other useful responses
to coordination challenges…
 Reengineering
 Total quality management
 PDSA
 Lean/ six sigma
 Improvement science
Addressing technical issues is
necessary - but not sufficient
“We’ve been doing process improvement for
several years, and we think we’re on the right
track. But we’ve tried a number of tools for
process improvement, and they just don’t
address the relationship issues that are holding
us back.”
- Bob Hendler, Tenet Healthcare Systems
Why does RC improve
performance?
Relationships of shared goals,
shared knowledge and mutual respect
create an organizational culture that supports
process improvement
Why does RC improve
performance?
Relationships of shared goals,
shared knowledge and mutual respect
help co-workers to see how they connect
around the clients
Family
Members
Neighbors
Job Training
Friends
Employers
Citizens/C
lients
Teachers/
Childcare
Co-Workers
Healthcare
Providers
Case Managers
When does relational
coordination matter most?
Task interdependence
Uncertainty
Time constraints
Are these conditions
present in your work?
Task interdependence
Uncertainty
Time constraints
How well does relational
coordination work in your
organization today?
Like this?
Shared goals
Frequent
Shared knowledge
Timely
Mutual respect
Accurate
Problem-solving
communication
… or this?
Functional goals
Infrequent
Specialized
knowledge
Delayed
Lack of respect
“Finger-pointing”
communication
Inaccurate
How does your
organization support
relational coordination –
or not?
Design organizational structures to support RC
Structures
Select & Train for Teamwork
Shared Accountability &
Rewards
Shared Conflict Resolution
Leader & Supervisor Roles
Boundary Spanner Roles
Relational Job Design
Team Meetings
Shared Protocols
Shared Information Systems
Relational
Coordination
Frequent
Timely
Accurate
Problem Solving
Communication
Shared Goals
Shared Knowledge
Mutual Respect
Performance
Outcomes
Quality & Safety
Efficiency & Finance
Worker Engagement
Client Engagement
Innovation &
Learning
Bottom line
Structures can be designed to WEAKEN
relational coordination or to SUPPORT
relational coordination
Leaders have a role in designing and
implementing ALL of these structures
Many opportunities to improve –
but where to start?
Structures
Select & Train for Teamwork
Shared Accountability &
Rewards
Shared Conflict Resolution
Leader & Supervisor Roles
Boundary Spanner Roles
Relational Job Design
Team Meetings
Shared Protocols
Shared Information Systems
Relational
Coordination
Frequent
Timely
Accurate
Problem Solving
Communication
Shared Goals
Shared Knowledge
Mutual Respect
Performance
Outcomes
Quality & Safety
Efficiency & Finance
Worker Engagement
Client Engagement
Innovation &
Learning
Changing structures is not enough
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Change rarely occurs simply by changing
organizational structures
Relationship patterns are deeply engrained
in our organizational cultures and
professional identities
Need to change relational patterns directly
Many stories of change
Dartmouth-Hitchcock
 Group Health
 Kaiser Permanente
 Stanford Medical
 Varde Municipality
 Billings Clinic
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Dartmouth-Hitchcock
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Dartmouth-Hitchcock
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Well-known medical center in New England
with long history of clinical excellence and
organizational innovation
At the cutting edge of payment reform, process
improvement, microsystems, and shared
decision-making with patients
Building a regional Accountable Care
Organization, led by CEO James Weinstein
64
Dartmouth-Hitchcock
“Imagine a health system that focuses on
health, not just health care. Our solution to
the current health care model is to eliminate
fee-for-service and provide service that is
rewarded for quality and results, rather than
volume.”
- CEO James Weinstein
65
Dartmouth-Hitchcock
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These new goals created pressure to reduce
costs and increase quality throughout system
In 2013 Rich Freeman, Chair of Surgery,
launched a transformation effort
From traditional silos of expertise toward
team-based model of care
Some urgency due to payment reform, as well
as quality and morale issues
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Dartmouth-Hitchcock
“There were a few wrong site surgeries
and near misses [which] happened despite
compliance with the checklist and timeout.
The issue was rote completion of the
checklist, and there wasn’t any
communication and feedback.”
-Giri Venkatramen, Associate Quality Officer
67
Dartmouth-Hitchcock
"I think morale across the organization is
troubled. And I think within surgery, some of the
sections are particularly troubled because for the
first time ever they're having trouble making
budgets. Normally surgeons are the ones who
bring in the bulk of the money for institutions sort of prized and highly valued and right now
we're just expensive."
- Dale Collins Vidal, surgeon and unit chief
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Dartmouth-Hitchcock
"Fundamentally, the most efficient care ... will be
the most coordinated care, and coordination
requires positive and productive relationships
along with robust process improvement. You want
relational coordination at the level of the patient,
as opposed to the patients being the hub of a
bunch of silos that don’t connect with each other.
What we’ve got now is still basically
uncoordinated care.” - Rich Freeman, Chair of Surgery
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Dartmouth-Hitchcock
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Change effort in 11 surgical units launched by
Freeman, and fellow surgeon Jack Cronenwett
Leadership coaching provided by outside consultant
Eddie Erlandson to enable leaders to “become
vulnerable and hear from others how they can do
better”
Develop team coaching skills to activate
interprofessional improvement teams by Margie
Godfrey and Tina Foster (co-directors of Microsystem
Academy)
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Overall plan
• Section Chief executive coaching (December, 2013 )
– 360 feedback, off-sites with Eddie Erlandson
• RC Survey (January, 2014)
– Current status of our teamwork
– Highlight opportunities for improvement
• Coach the Coach Program (February, 2014)
– Develop coaching skill in each section
– Work on improvement initiative with section during
course
– Continue long term development after coaching
course
– Periodic meetings of DHMC coaches to share learning
• Repeat RC Survey (January 2014)
– Have we changed? What are new opportunities?
Eleven participating surgical units
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Vascular
Urology
Transplantation
Plastic surgery
Pediatric surgery
Otolaryngology
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Ophthalmology
Neurosurgery
General surgery
Dermatology
Cardiothoracic surgery
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Relational coordination
• Evaluates processes and teamwork, not individuals
• Scores are a starting point to inform improvement
• The GOAL is to improve performance!
– Not just to improve teamwork (but they are correlated)
– Not just short term project (marathon not sprint)
• Method:
– Improve teamwork in the context of our regular work
– Work together to improve an important process
– Lead to sustainable improvement, with cross over to other
projects and other team members
• Each person can make a big difference
Dartmouth-Hitchcock
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Measured RC across all workgroups on each unit
Response rates very high - 75%, 85%, 86%, 90%, 92%,
92%, 93%, 94%, 97%, 100%, 100%
Scores varied across units, with high and low outliers,
and some common themes across the units regarding
the seven dimensions
Goal was to feedback survey results almost
immediately to each unit, with facilitated time to
discuss and determine improvement steps
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Feeding back the data
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Dartmouth-Hitchcock
”We held two sessions with the coaches and
champions to prepare them for sharing the RC
scores with their sections. This included
rehearsals of what they will say and do with
their group. Since some of the coaches are
surgeons who have a mindset of diagnosis and
being prescriptive, having them practice how
they will coach the group was very important."
-Margie Godfrey, Coach
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Discussion before seeing data….
• Which RC dimension will score high or low?
• How much variation do you expect between sections?
• How much insight do you have into this dimension of
teamwork? Will you be surprised by the results?
• Do you think your RC scores will correlate with your
overall impression of your section’s performance?
Dartmouth-Hitchcock surgery department:
How can we improve performance across
surgical sections?
Practice
Manager
Surgeons
Nurses
Nursing
Assistants
Coordinators
Patients
Advanced
Practitioners
Technologists
Secretaries
Residents
Feeding back the data
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Feeding back the data
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Discussion
• Initial thoughts?
• What are section plans going forward?
– Retreats, regular discussion at meetings
• What do sections need to improve?
– Coaches: networking, time, leadership
engagement
– More instruction? Relationship course?
• Should we meet again to discuss before
section meetings?
Examples of post survey interventions
(unique for each section based on findings and goals)
• Group discussions r/t
practice improvements
and the general work
environment
– Developed shared vision of
practice, behavior
standards
– Determined new
communication patterns
such as huddles, all staff
meetings, email turn
around times
– Important role of the
practice manager to
facilitate new patterns
• Discussed and
“translated” the findings
– Group determined
behaviors standards and
met regularly to hold each
other accountable
– Monthly coaching sessions
specific to topics in
findings
– Explored new
communication skills and
processes including new
meeting skills
Creating change at the frontline
"We did group exercises with the RC data. Not just
with the improvement team but with everyone in
the section. I developed some scenarios based on
what I hear people talking about in the halls,
outside my office. The scenarios were betweengroup, like between physicians and other groups.
Some of them were simulations like 'here's your RC
data and here's your budgetary data. What would
you do?' The scenarios involved everyone,
including the practice manager, our section chief,
and our nurse manager."
-Annette Tietz, Coach for Otolaryngology Section
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Creating change at the frontline
“The surgeons were surprised by the RC results.
Their ratings of others were pretty high, but the
ratings of them were not as high. It was an eye
opener for them. I also did one-on-ones with all
the surgeons to show them what we need from
them with the After Visit Summaries.
Everybody's have improved.”
-Annette Tietz, Coach for Otolaryngology Section
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Fast forward one year to
January 2015!
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Discussion
• Will your RC data be different this year? Why?
• How has the improvement team and coaching
process affected this in your section?
Survey Response Rates
91% Baseline, 2014; 89% Follow-up, 2015
Relational Coordination
Surgery Department
5= Always, Completely ; 4= Often, A lot; 3= Occasionally, Somewhat
4,5
> 4.5 = High
Performance
2014
2015
> 4.0 = High
Performance
4,0
3,5
3,0
Between
Groups
Within
Groups
Combined
Relational Coordination by
Section
4,5
4,0
3,5
3,0
CT
Derm
Gen
Neuro Opth
2014
Otol
2015
Ped
Plast
Trans
Urol
Vasc
Relational Coordination 7 Dimensions
5,0
Between Groups
2014
2015
4,5
4,0
3,5
3,0
Frequent
Timely
Accurate
Problem-Solving
Shared Goals
Communication
5,0
Within Groups
2014
Timely
Problem-Solving
Shared
Knowledge
Mutual Respect
2015
4,5
4,0
3,5
3,0
Frequent
Accurate
Communication
Shared Goals
Shared
Knowledge
Mutual Respect
5= Always, Completely ; 4= Often, A lot; 3= Occasionally, Somewhat
Drill Down into Details - Workgroup Effects
Looking forward – next steps
“Next we will redefine the microsystem away
from our administratively drawn boundaries to
one that centers around the patient. We will
measure relational coordination among team
members, including the patient and the family.
We will apply what we learned about
leadership, relational coordination and process
improvement to improve the patient
experience.”
-- Rich Freeman, Chair of Surgery
Kaiser Permanente
Kaiser Permanente
 Kaiser
Permanente is the largest private
healthcare system in the U.S.
 Structured as a health maintenance
organization, with 8.3 million members
 “The less we do, the more money we
make” – incentive is to keep members
healthy
Kaiser Permanente
 Organized
 Southern
in 7 regions
California
 Northern California
 Georgia
 Colorado
 Hawaii
 Mid-Atlantic
 Northwest (Oregon and Washington)
Northwest Region
 500,000
members
 11,000 employees
 33 medical clinics
 Only 2 hospitals
 A focus on keeping people OUT of the
hospital
 Also highly unionized in all work groups
The challenge
 Challenge
to provide affordable, high
quality care and patient experience
across an organizational structure with
traditional silos
 Need to change how care is delivered for
complex patients
The challenge
“It is apparent to me that the only way to
achieve our full value as an integrated delivery
system is to operate more effectively across
departmental lines. Our members don't care
how we structure ourselves as departments;
they only care that the services they receive are
coordinated and delivered in a caring manner.”
- Wendy Watson, Regional VP
The challenge
“It’s just that in our organization, and I think in
all organizations, people talk if they’re within
the same reporting structure. But if you get
outside of that reporting structure they tend not
to talk to each other.”
- Ellie Godfrey, Regional VP, Patient Service
The challenge
“You see in every direction there was tension,
even within teams. For example social workers
not understanding what nurses and pharmacists
do and vice versa; and not really having clear
guidelines about who does what and why, and
how you come together on behalf of the
patient.”
- Ellie Godfrey, Regional VP, Patient Service
Ideas for change
 Fall
2014 several initiatives to build
collaboration and teamwork
 Complex Care Medical Home
 At first, focused only on process
improvement – no focus on
communication and relationships
 Learned about relational coordination
The intervention
A credible relational leader – Gena Bailey –
was the Senior Service Administrator
 “When I heard about relational coordination, I
thought that it was exactly what we need and
it’s evidence-based. So, it will move quicker
and move our work quicker. It would have
taken me years to build cross-functional teams
in the Portland metro area – years.”
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Building support
Got local physician leadership on board, after
initial skepticism
 “I was skeptical and frankly thought it would
be a big investment of time without any
benefit.” – Mark Harvey, MD
 Also got the union leaders involved, using the
Labor Management Partnership
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Intervention used existing governance structure
The intervention
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Internal consultants measured RC and shared
highly detailed results with all participants
 “We
thought that people were ready to see
everything, so we shared it.”
 Participants
decided what to do about the
results – for example shared knowledge
 Two interventions – living room huddles and
job shadowing
Living room huddles
45 minute all staff gathering in the main lobby
prior to opening the building for patient care.
Staff were provided a light breakfast and
engaged to learn more about each other’s
roles and to understand all the different
departments
Highly effective for building shared
knowledge, shared goals, mutual respect
Adopted throughout KPNW
Living room huddles
“We lay the baseline far in advance - by having
managers go around and talk up the huddle in
the morning and how exciting it’s going to be
and how great it’s going to be helps people be
less anxious about the huddle."
Living room huddles
“Then when people arrive in the morning before
the clinic is open, there is a lot of excitement
and music is playing. Following an agenda
overview and making sure the leaders are
acknowledging that, ‘Yes, you’re here early, yes
we have an agenda, yes this is what our
outcome is and should be.'"
Conversations of interdependence
What is it about how we do our work that
helps you do your work?
How could we do our work differently to help
you even more?
When do we seem to be aligned and when do
we seem to be at cross purposes?
Job shadowing
“We had teams go and interview another
department for 20 minutes. So we had this
dyad [a physician and medical assistant] who
would go and shadow in Registration for 20
minutes and then come back and share what
they learned."
Early results
RC scores improved on every dimension
Best outcomes on employee satisfaction
Performance is starting to improve
Varde Municipality
Varde Municipality
 Danish
municipalities are responsible for
elder care, care for children and youth,
home care, drug abuse, homelessness,
handicapped, workforce development,
cultural activities and infrastructure
 Now also accountable for 20% of
healthcare costs if citizen is hospitalized
or visits a doctor
Varde Municipality
Current efforts:
 Wellness visits to all citizens 78 and older
 Outreach and support for citizens with
depression, joblessness, handicaps, drug
abuse
 “It doesn’t work to say do it because I am
the nurse and I said so. It has to connect to
something the citizen cares about.”
– Margit Thomsen, Director of Health Promotion
Varde Municipality
“Say you had a stroke - we know it’s better
to have exercise. That is part of this
change - that you take responsibility for
your own health. You cannot just go to the
doctor and say, 'Cure me.' Instead it's 'take
responsibility for your own life.’”
- Kirsten Myrup, Head of Health and Rehabilitation
Varde Municipality
“We also do rehabilitation for those who are
out of work. If you lose your work, you lose
your connections with work. Within six
months it is very tough to get you back into
work. It’s our job to get them healthy and get
them back to work again. This takes a lot of
collaboration between different people.”
- Erling Pedersen, CEO
Varde Municipality
“Now we have the challenge of working across
sectors and we don’t know how to do it yet.
These people have to get along and work
together. Sometimes it works – especially at the
beginning of the week [much laughter around
the table]. They need to have a good
relationship between each other and a good
dialogue - they need to know what is going on in
the other silos. Otherwise nothing works.”
- Erling Pedersen, CEO
Varde Municipality
“We also need to coordinate with the
GPs and the hospitals. It is a real
challenge for us. We each have our own
budgets and our own goals – we are not
clear about our shared goals and we
don’t have enough knowledge of what
each other does.”
- Kirsten Myrup, Head of Health Board
Project focus
Work Processes
Project Focus
Goals
A. Which organizational processes can
succesfully support the implementation
of strategic initiatives?
1. How can the Dementia Strategy
be implemntet effectfully?
Professional quality and client
quality.
B. How can specific training and OD
processes create a higher degree of
Relaitonal Coordinering?
2. How do increased RC affect the
implemntation of the Dementia
Strategy?
Higher RC after the training
and implemntation process.
C. How can specific training and OD
processes create a higher degree of
Strategic Relationel Leadership?
3. How do increased SRL affect the
the degree of RC?
Higher SRL after the training
and implemntation process
Baseline relational coordination April 2014
Social worker
Nurses
Low
Medium
High
Dementia
Consultants
Nurse
Assistant
Training
Nurse
Aid
CEO’s perspective
"This map and the red ties we see here just
reflect the way we told our employees to
work. We tell them you have to go and
work and do your job. We think we tell
them to work together – but that’s not
what they are hearing from us.”
Erling Pedersen, CEO
Frontline leader initiatives
"We discussed the map with the frontline
leaders and simply brainstormed possible
initiatives that could handle this thing. Now
we’re talking about two different things - role
clarification, and building spaces for cross
professional collaboration. Those are the two
main things they identified to work on.”
- Carsten Hornstrup, Consultant
Follow up january 2016
Social
Worker
Nurses
Low
Medium
High
Nurse
Assistant
Dementia
Consultants
Nurse
Aid
Training
Total RC up 30%
Relational coordination results
Opstart:
Faggruppe
Demenskonsulenter
Fys/Ergo
SSA
SSH
Sygeplejersker
Visitatorer
Total
Demenskonsulenter
Fys/Ergo
SSA
SSH
Sygeplejersker
Visitatorer
Total
4,71
2,24
2,61
2,33
2,43
3,52
2,97
2,24
3,47
2,73
2,59
2,00
2,78
2,64
2,52
2,00
3,54
3,50
2,81
2,36
2,79
2,29
2,14
3,61
3,54
2,81
1,96
2,73
2,51
2,05
2,91
2,86
3,45
2,83
2,77
3,41
2,98
2,85
2,78
3,00
3,51
3,09
2,95
2,48
3,04
2,93
2,75
2,83
2,83
Afslutning
Row Labels
Demenskonsulenter
Fysio-/Ergoterapeuter
SOSU-Assistenter
SOSU-Hjælpere
Sygeplejersker
Visitatorer
Grand Total
Demenskonsulenter
4,75
3,00
3,71
3,29
3,71
3,90
3,69
Fysio-/Ergoterapeuter
2,90
4,15
3,53
3,32
3,28
3,40
3,43
SOSU-Assistenter
3,65
3,16
4,03
3,95
3,63
3,12
3,61
SOSU-Hjælpere
3,63
3,42
4,15
4,20
3,75
3,37
3,77
Sygeplejersker
3,70
3,19
3,55
3,37
3,88
3,42
3,52
Visitatorer
4,67
3,86
3,63
3,24
3,67
4,80
3,98
Grand Total
3,65
3,34
4,00
3,95
3,70
3,33
3,68
Quality indicators
Der er formuleret handleplaner for arbejdet med den enkelte demente borger.
(Establisched coordinated plans for each citizen)
Der er velbeskrevne og kendte roller og ansvarsområder for de enkelte faggrupper i
forhold til arbejdet med demente borgere.
(Well described and know roles)
De enkelte faggruppers kompetencer bruges aktivt i arbejdet med demente borgere.
(Use of all professionals skills)
Der er sammenhængende forløb i arbejdet med demente borgere.
(The work around demented citicenz are coordinated)
De pårørende oplever at de er reelle samarbejdspartnere og ressourcepersoner, der
inddrages under hele sygdomsforløbet.
(Relatives experience to be involved and to be valued partners)
Demente borgere tilbydes aktiviteter, som er tilpasset borgerens fysiske og kognitive
formåen. (Dementet are offered customized activities)
Demente borgere har så meget medbestemmelse som det er muligt.
(Demented have as much influence as possible)
De pårørende bliver klædt på til at tage medansvar for opgaverne omkring demente
borgere. (Relatives are helped to take co-responsibility)
Gennemsnit
Opstartsmåling
Afslutningsmåling
2,89
3,48
2,13
3,42
1,93
3,71
3,09
3,64
3,11
3,48
2,89
3,52
3,57
3,97
3,11
3,29
2,59
3,56
+37,5%
Family Consultant
for Dementia
Family consultant
“We are better at getting in touch with each
other across boundaries to discuss the
complicated cases. Maybe especially nurses and
visitation. We have become better at involving
all parties – including citizens and relatives. And
it improves the quality of what we do. "
Nurse
Leaders
NurseTeam
team leaders
“I don’t get as many complex dementia cases referred
to me as I used to. I see as a sign that we as a collective
are better at handling these complicated cases
effectively, earlier in the process.”
“It means that when things are getting difficult – there
are more people who collaborate and help me deal
with the difficulties.”
“I don’t think this is only the experience of the nurses. I
think it’s happening for all of us who work with the
citizens. We have moved closer together."
Headof
of Home
home care
Head
Care
”There is a general perception that the
collaboration across the different professions
has improved. It simply gets more attention.
Especially the team leaders have given it more
attention. The cross boundary coordination
meeting gets much more attention. This gives
better dialogue – not just around citizens with
dementia, but also around other complex
issues.”
Top leader initiatives
Now top leaders are looking for ways
to support these changes, for example
combining budgets and developing
new agreements with hospitals and
GPs
Three kinds of interventions
Relational interventions to build the
new relational dynamics
Work process interventions to connect
new relational dynamics to
improvements in the work
Structural interventions to support the
new relational dynamics
Relational model of organizational change
Structural Interventions
Select & Train for Teamwork
Shared Accountability &
Rewards
Shared Conflict Resolution
Boundary Spanner Roles
Relational Job Design
Shared Meetings/Huddles
Shared Protocols
Shared Information Systems
Relational
Coordination
Frequent
Timely
Accurate
Problem Solving
Communication
Shared Goals
Shared Knowledge
Mutual Respect
Relational Interventions
Create Safe Space
Relational Assessment
Humble Inquiry/Coaching
Performance
Outcomes
Quality & Safety
Efficiency & Finance
Client Engagement
Worker Engagement
Learning &
Innovation
Work Process Interventions
Assess Current State
Identify Desired State
Experiment to Close the Gap
Relational model of organizational change
Middle & Top Leadership
Structural Interventions
Select & Train for Teamwork
Shared Accountability &
Rewards
Shared Conflict Resolution
Boundary Spanner Roles
Relational Job Design
Shared Meetings/Huddles
Shared Protocols
Shared Information Systems
Frontline
Leaders &
Co-Workers
Relational
Coordination
Frequent
Timely
Accurate
Problem Solving
Communication
Shared Goals
Shared Knowledge
Mutual Respect
Relational Interventions
Create Safe Space
Relational Assessment
Humble Inquiry/Coaching
Performance
Outcomes
Quality & Safety
Efficiency & Finance
Client Engagement
Worker Engagement
Learning &
Innovation
Work Process Interventions
Assess Current State
Identify Desired State
Experiment to Close the Gap
Stanford University Press, 2016
Role of measurement in change process?
 Possible to measure relational coordination
o Within workgroups
o Between workgroups
o Across highly distributed networks
o Can include clients and their families
o Can measure at any level of leadership
o Across levels of leadership
RC Survey Questions
© 2016 Relational Coordination Analytics, Inc. All Rights Reserved
RC and its Seven Dimensions
Between Workgroups
N=104
© 2016 Relational Coordination Analytics, Inc. All Rights Reserved
RC Network Map
© 2016 Relational Coordination Analytics, Inc. All Rights Reserved
RC Matrix
Ratings of
Admin
CC
PCAs
Phys
PA&NP
RNs
ResTh
1.79
1.79
1.79
1.79
1.79
1.79
1.79
4.43
4.86
4.29
4.52
4.71
4.67
3.86
2.62
2.40
4.02
2.29
2.29
3.50
2.40
3.58
4.26
3.47
4.25
4.19
3.84
3.50
3.75
4.29
3.39
4.30
4.55
3.96
3.20
Registered Nurses
3.37
4.08
3.70
3.55
3.98
4.22
3.49
Respiratory Therapy
2.57
2.57
2.57
3.14
3.14
3.43
4.00
Administrative Support
R
a
Care Coordination
t
i
n Personal Care Assistants (PCAs)
g
s
Physicians
b Physicians' Assistants and Nurse
y Practitioners (PAs & NPs)
© 2016 Relational Coordination Analytics, Inc. All Rights Reserved
A tool for change
 Share RC measures with all participants to
inform organizational change
 “Looking into the mirror”
 “Putting the elephant on the table”
 A starting point for new conversations
 A starting point for reflection and change