Relational Coordination Research Collaborative

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Authentic Presence, Relational Coordination, and Results: The Finger Lakes Dialogue on Relational Workplaces

Join us on June 22-23, 2013

Finger Lakes Dialogue June 22-23, 2013The Finger Lakes Dialog is a weekend workshop in the beautiful wine and waterfall country of upstate New York, sponsored by The McArdle Ramerman Center and the Relational Coordination Research Collaborative. This year’s guest presenter is Diane Rawlins, a coach and consultant who was part of the formation of the positive organizational psychology movement.

Shared goals, understanding and respect
We know from a robust body of research that organizational performance depends upon relational coordination—the ability of people involved in shared work processes to integrate their tasks and manage their interdependence.
But how do leaders help them do that? How do they foster the shared goals, shared understanding and mutual respect that are the essence of relational coordination?
Various organizational structures and practices have been suggested—and can indeed be helpful—but a deeper factor is also needed: the authentic presence of the leader. Without authentic presence, these tools can be experienced as superficial or insincere, and can even breed cynicism rather than engagement.

Authentic presence
But what, exactly, is authentic presence? What does it look like in action? Diane Rawlins characterizes it in terms of two core capacities, self-differentiation and attunement. These qualities in the leader call forth similar qualities in followers and engender trust, respect and the free flow of information and ideas within the work group.

Join us June 22-23!
We invite you to join Diane and Finger Lakes Dialog host Tony Suchman for an energized and highly interactive session (maximum 20 participants). We’ll explore practical ways to deepen your own authentic presence and to foster it in others and we’ll develop new insights about teams, organizations, performance and leadership.
This workshop will also give you an opportunity to experience the beautiful views, forest trails and vineyards of New York’s Finger Lakes region. It will be held at an artist’s private hillside home and studio in Montour Falls, NY and includes dinner at a Seneca Lake winery.  Click here to register.

Diane B. Rawlins, founder and principal of InsideOut Consulting, LLC, partners with healthcare leaders and their teams to build their capacity to transform organizations. She helps them develop a mature understanding of self and purpose, ground their actions in their convictions and compassion, forge collaborative relationships with diverse stakeholders, and mindfully attend to both outcomes and process. Diane is currently a senior consultant for several major healthcare systems, including Group Health Cooperative in the Pacific Northwest.

Tony Suchman is a practicing physician, Clinical Professor of Medicine at the University of Rochester, and the head of The McArdle Ramerman Center's Healthcare Consultancy. Drawing upon diverse interests and experiences, his work focuses on improving human interaction and collaborative decision-making across all levels of healthcare-from the front lines of patient care to the executive suite and boardroom. His most recent book, "Leading Change in Healthcare: transforming organizations using complexity, positive psychology and relationship-centered care," has recently been published by Radcliffe Publishing. 

Time, location, travel
The workshop will take place from noon-5:00 on Saturday, June 22 and 9:00-1:00 on Sunday, June 23. Lunch on both days is included as is the winery dinner, which will take place Saturday evening at 7:30 pm. The workshop site in Montour Falls is a half-hour drive from Ithaca and Elmira-Corning (the closest regional airports) and a 90-100 minute drive from Rochester (the closest airport served by all major airlines). We will provide detailed driving and accommodation directions to registrants.Local accommodations (not included in the registration fee) include luxury hotels, streamside cottages, Bed & Breakfasts (each with their own unique personality) or comfortable, inexpensive motels.

For more details, visit ; to sign up, click here.
See you in the Finger Lakes!

Click Here for a pdf version of the event details to share and print. 

Reflections from the RCRC Community on Epic Systems and Other EHRs

March 20, 2013

Epic Systems

RCRC's Executive Director, Jody Hoffer Gittell, shares her reflections on what she learned during her recent visit with Epic Systems in Verona, Wisconsin:

I was in Madison last week to speak at the University of Wisconsin School of Business, hosted by friend and fellow MIT grad Chip Hunter who is now a dean there.  Led by Chip's colleague Mark Covaleski, we were invited to spend much of the day with Epic Systems -- soon to be the largest EHR vendor in the US it would seem based on current trends -- they serve several of RCRC's partners and clients including Dartmouth, Kaiser, Group Health and most recently Partners Healthcare.  I could say a lot about the people of Epic (Katie O'Brien and Jacob Engel and Sarah Carroll and Leela Vaughn are terrific) and the funky campus they have built (somehow weaving together cow themes with intergalactic themes if you can picture that)!  Also a fun sliding board from the second floor to the first if you need to get down quickly...  Jody at Epic

But for now let me share just a few things.  Epic was started in 1979 by Judy Faulkner, who programmed data for some MDs who were doing research in an outpatient setting.  They started with 3 people, then up to about 400 people 10 years ago, now at 6,200 and moving toward 11,000.  Their product has taken off for many reasons but one in particular I think - they were designed from the start for the outpatient setting, moving eventually into inpatient but with a solid foundation in coordinating the complexities of outpatient care, including a well-developed interface with patients and families.  Other EHRs have tended to start in inpatient then move to outpatient from there eventually.  In the emerging era of accountable care, with the likelihood of rewards for delivering good population health, outpatient care is now KEY and Epic was designed to support it.

Of course there is always room to do this even better, for example going beyond the technical infrastructure to support the relational infrastructure of care coordination.  As a colleague in one major health system said:  "Tying Epic to RC would be huge in terms of what we are doing here."  The same could be said for other EHR vendors.

Responses from the RCRC Community  

From Paul Levy, former CEO of Beth Israel Deaconess:

Another view!

From a colleague in a multi-state healthcare system:

"Using the patient-centered information in the medical record to connect the provider care team with RC's focus on shared goals and shared knowledge would seem to be a very powerful and exciting combination." 

From a colleague in a Georgia healthcare system:

"[We just adopted Epic because] it is widely regarded as the best clinical solution in the marketplace today... You are correct in pointing out that Epic is built around the ambulatory side, and it will be interesting to see over the next few years the extent to which the patient is allowed to view their own patient record in the network. It is very much dependent on the provider, and typically a very limited view is allowed. For instance, the functionality exists on the provider side to track and graph patient vitals, A1C, lipids over time, and the patient view of their record (PHR) can be a reflection of the provider view (EHR). But for most networks, the patient view (PHR) is highly restricted; in our personal case it is just an email system to and from the office providing notification that lab tests are complete! Legal issues are the main reason for this restraint, but I hope that over time this changes, so that all the money spent on these systems is allowed to provide benefit to patients themselves."

From a colleague in a California healthcare system:

"I love the direction you are going.  Linking the technical with the relational - just what is needed.  There are so many possibilities." 

From Tage Kristensen, Danish consultant/academic:

"Thank you so much for this and many other informative mails. The issue of EHR vendors is of course relevant in many countries.  I looked at a quality assessment in which Epic was only ranked as the 6th best. (Although it had the highest number of users)." 

From Shirley Gibson, Virginia Commonwealth University Health System:

"Relational coordination is pervasive in every piece of work I do on a daily basis...You have uncovered the basic theory of all interactions. As I read these interesting reflections on Epic, I thought I would ask you if you wanted to consider doing any comparisons with other information systems.  We are a Cerner platform and are working with our Deputy Director to coordinate a visit for Secretary of Health and Human Services, Kathleen Sebelius. Cerner is a competitor so comparison might be relevant?  Just a thought!"

Interview with Amy C. Edmondson, Author of "Teaming"
By William Brandel, RCRC, Brandeis University

February 13, 2013

Amy EdmonsonTeamingAmy C. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. Edmondson's research examines leadership, learning and innovation in teams and organizations, and has been published in numerous academic and managerial articles. Her book, Teaming: How organizations learn, innovate and compete in the knowledge economy (Jossey-Bass, 2012) highlights how continuous improvement, understanding complex systems, and promoting innovation are all part of the landscape of learning challenges today's companies face. Organizations, Edmondson argues, thrive based on how well small groups – teams – within organizations work with each other. The pace and breadth of change in today’s world demands leaders who can create an environment where individuals can team, and teams can succeed.

Edmondson spoke to RCRC about her book, and about what teaming means for relational coordination and healthcare.

How does teaming advance the concept of Relational Coordination?
I think that relational coordination is very much about effective teaming. Relational coordination is a very precise and helpful way to measure and encourage good coordination. Relational coordination says first and foremost it’s not just a task, not just the tool, or the technical work that we do when we talk about relational coordination. Coordination must fundamentally happen between people who are emotional beings, and who have to connect with each other in genuine ways for it to work. Relational coordination calls attention -- by design -- to aspects of the relationship side of work coordination. It recognizes that the relational side of coordination is essential for organizational effectiveness. In that sense, Relational Coordination and Teaming emphasize the same phenomena, but use different windows to talk about the challenges we confront in making positive change.
When I talk about teaming, the gap I am addressing is that people are too individualistic and pay insufficient attention to their interdependence and thus to the need to work together. I am saying that the gap here is for people to recognize that they are interdependent. Similarly, the relational coordination construct and research were inspired by Thompson’s understanding of the different kinds of coordination in organization, and by the central importance of what he called “reciprocal coordination” – where back and forth communication was central to effectiveness. Both traditions – relational coordination and teaming – recognize that we can’t coordinate well while being insensitive to relating to each other.

Concerning healthcare, what do you think is the next step to move toward more coordinated delivery of care?
I believe the next step in healthcare is leadership development. By the way, this is starting to happen more and more. By leadership development, I don’t just mean CEOs or chiefs of service lines, but helping to develop people at all levels of healthcare industry in some basic practices for developing and influencing others, and for encouraging and engaging collaboration in new ways. One thing going for us in healthcare there is no shortage of intrinsic desire or motivation to do the right thing. The challenge becomes shifting individualistic mental models. The industry has grown up with a mental model that says, “if I do my job well and you do your job well, the patient will get the best care.” That was once was true, in earlier eras of health care, a century, or even a half century ago. Today it is anything but true.

There are some aspects of teaming in healthcare. For example, in surgery. What is missing?
What is missing is a deep awareness of interdependence – in caring for both hospitalized patients and patients in general, even in surgery. This stems from the culture of the profession, which is grounded in individual expertise. This kind of professional culture is not just characteristic of healthcare. The mindset of a professional is the study and practice of a deep and relevant body of knowledge – one with important relevance to problems in the world. This mindset, historically, has been, “I go to school to master a profession, and then I go to work to exercise that mastery and expertise.” A professional, in short, is someone who masters important expertise and applies that expertise in the world. This notion of an essentially solo activity was for years appropriate in healthcare, and still may work well in some other industries.
However, today, particularly with the balance shifting from mostly episodic care to mostly caring for patients with chronic conditions, the work is becoming an ongoing, teaming process -- whereby we monitor, help, and encourage patients to be part of that collaborative process. The world has slowly changed around us, and our mental models of an individual professional who can do what it takes to get the job done are out of whack with the new reality of the care process.

You had mentioned that the idea of teams is in decline but that the idea of teaming is ascending. What does that mean?
I wouldn’t say the idea of teams is fading or dying, but rather that the reality of formal teams in 24/7 industries like healthcare -- and many others with extremely fluid work contexts where we require staffing flexibility that precludes the composition and maintenance of stable and formal teams -- is on the rise. It’s not that teams are not good; it is just that in many settings it is no longer realistic to go that route, to say, “okay, let’s put together well-composed, well-designed, well-practiced teams, and they will do better work than otherwise.” Absolutely, they will. But back up: Can we actually do that? Not really, because people have different shifts, different needs, and the ability to keep stable work partnerships together is pretty low in healthcare.
What does that mean for health care organizations? It means that the need for collaboration isn’t going to go away. And if we can’t rely on formal, stable teams, then we have to get good at teaming – at the activities and processes of collaboration and coordination of teamwork, rather than the structures and designs of teamwork.

Do people have a natural ability to team? Or do we have to overcome what comes naturally to us, in order to team?
We are born with natural curiosity, which is an absolutely essential aspect of teaming. If I’m not curious about who you are and what you bring, then I am unlikely to be very good at teaming because I am just looking at the world through a very self-centered lens. We’re born with that, but as we go through school and grow older, we can very easily lose that curiosity. That which is natural (meaning we are born with it) and that which is socialized is not always the same thing
What do we need? We need in a very basic way to be as interested in what another person is bringing to the party as what we are bringing, in what they are hoping to get done as in what we are, and very importantly, what they are up against. What are they up against means the little barriers and hurdles that might get in the way of their ability to do their best work. It is not written across their forehead, and so we often don't realize that we’re unaware of the hurdles others might face. What I am describing is the ability to balance advocacy and inquiry, which Chris Argyris has described for so long. This does not come naturally, as it turns out. It certainly does not come naturally to adults, even if it may come naturally to children.

Does the ability to team emerge, or become hardwired at a certain stage of development?
That is a provocative idea, and the answer is probably “yes.” I don’t have my own data on that, but I would argue that higher stages of adult development, which bring greater self-awareness and emotional maturity, would be helpful in effective teaming. Once has to realize that the work ahead is “not about me,” it is about us and what can we do together.

Should teaming, as a concept, be given greater emphasis in the workplace?
It’s a useful device to get people thinking about communicating and collaborating, to get their attention. When I say “teaming,” people know what that means. It means coordinating, collaborating, sharing, working together, being far more integrated and open than one might naturally be. It’s not a program or set of specific activities and practices that are brand new to the world, but rather more of a mindset that people at all levels of complex organizational systems need to keep in mind so that we can think differently and act differently.

Your book examines some very interesting and dramatic examples of where teaming was successful, in particular, the Chilean mining rescue. In that instance, the rescue depended on the teaming among government, engineers, and the miners, themselves. What are the lessons that we should take away from that experience?
First, it was a novel situation. There was no blueprint, no solution. The only way to develop a solution was to innovate, to come up with something together, through immense dedication and persistent trial and error. And that necessarily took place across boundaries of all kind -- geographic, national, expertise-based, and hierarchical. The lesson we can take away from that case is what initially seems truly impossible is sometimes doable, through highly effective teaming.
They had to do everything right in that rescue operation. This does not mean not fail -- they failed many, many times; in fact, several times a day. But, they had to do everything right in the collaborative, interpersonal sense, in the listening, in the engaging, and the persisting through failure.
In this particular extraordinary case, I saw teamwork – teaming – underground, above ground, and ultimately between them. All of that teaming had to be done in a very open, straightforward, dedicated way. Perhaps most of all, it required careful listening and synthesizing of different ideas and points of view. This is not easy and it doesn't happen spontaneously. It takes very effective leadership to encourage people to bring their best selves to the situation – to offer ideas, to listen, to help, to leave their egos at the door.

Here in the U.S., there is a strong element of individualism that goes to the core of our identity. Does that impact our ability to team?
I think that this may make teaming more difficult for us. Yes, I do think that we can be handicapped by that. But, at the same time, we are also pragmatic people, and after we diagnose a situation appropriately, we will generally jump in and do what it takes to coordinate and collaborate. In this way, we’ve done amazing things: We put a man on the moon and brought him back safely. So I think we can do it – engage in teaming, that is. And perhaps I don’t think it is as much a problem for Americans in general, as for the healthcare industry (in particular), where the professional individualistic mindset is salient. This is not so much about American individualism as about training and expertise. I think as Americans, we cherish individualism but we are eager to and highly capable of engaging with each other to do things we could not do alone.

Putting culture aside, is there a basic desire for a person to seek individual action and reward in the workplace? Or is that trumped by a need to belong in an organization?
I think there’s a balance. We don’t want to get rid of individual identity or individual differences. We need different expertise, and we must value different opinions and mindsets, to innovate and do many things that are worth doing. It’s not a matter of just nurturing the strong collective identity as one might find in other cultures, but rather of developing more skill in using the differences we have collaboratively to accomplish ambitious goals that we could not accomplish alone.

How do you foster that teaming mindset?
In a word: Leadership. People need to be invited into a new way of operating and they need to be challenged to do that. The leadership process is about getting people to first envision the possibility of what needs to be done. If I can envision and communicate that, then I can get people to start thinking about what their part of the journey might be.
Then I need to enroll them. I have to make it more personal to them, and I need the individual to understand that I need their help.
The third step is to engage them in the actual work. We have to stop talking and start trying. The trying will be fraught with failure along the way. We will try something that is beyond our starting point, and it will fail, and then we will have to celebrate that, talk about that and figure out what we learned and do something else.

Understanding and Creating Caring and Compassionate Organizations

January 28, 2013

AOM logoIn October 2012 Jody Hoffer Gittell and Anne Douglass' article, “Relational Bureaucracy: Structuring Reciprocal Relationships into Roles,” was published in a special issue of the Academy of Management Review, dedicated to the subject of care and compassion in organizations. This month, the Academy of Management features a panel discussion among several editors and authors who contributed their unique perspectives and expertise to that October special issue. The forum, titled “Understanding and Creating Caring and Compassionate Organizations,” is devoted to the challenge of integrating care and compassion into the core values of organizational management. This theme aligns with relational coordination theory, which brings to light the humanistic elements that underly the technical process of coordination. Relational coordination is coordinating work through high quality communication supported by relationships of shared goals, shared knowledge and mutual respect. According to relational coordination theory, “organizational practices and structures can either foster and support positive human relationships or substantially undermine them, even if unintentionally.”

The panel discussion has now been posted as a “Featured Story” on the Academy of Management website homepage (, including a video commentary by Professor Jane Dutton of the Ross School of Business, formerly a Board Member of the Relational Coordination Research Collaborative. The AOM invites the public to engage with the panel discussion and video by offering comments, insights, and reactions to this important topic. The webpage dedicated to this discussion, featuring a video/audio podcast and transcript of the panel is For the initial press release by the Academy of Management, click here. For access to the "Relational Bureaucracy" article as well as the rest of the special issue, click here.

Danish article from Lederweb "Coordinate Work Together - And Create Collaboration"

January 3, 2013

Jody Hoffer GittellRelations are important to daily work, whether related to management related contacts, internal group relations, or the relation to other departments, according to Frida Louise Irhøj Damhus of the Danish organization, Lederweb. Read her interview with professor and award-winning author Jody Hoffer Gittell during her visit to Copenhagen in September 2012. (translated from Danish by Thim Prætorius).
Read the article here.

Anna Perlmutter Wins Recognition for Research on "Shared Space as a Tool for Relational Coordination in Multi-Organizational Networks"

November 20, 2012

Anna PerlmutterShared space fosters relational coordination between organizations, according to Anna Perlmutter of Brandeis University, enabling organizations to find operational efficiencies and to foster potential synergies through innovation and collaborative knowledge sharing. This conclusion arose from Perlmutter's analysis of current trends and research on spatial design and collaborative practices for organizations using theories of relational coordination, networks, and team facilitation and was developed in her Organizational Theory course with Professor Jody Hoffer Gittell at Brandeis University's Heller School. The resulting paper, "Shared Space as a Tool for Relational Coordination in Multi-Organizational Networks," was selected by the Organizational Development Network as one of two student papers to be presented at its national conference in Phoenix, Arizona in October 2012.

According to Perlmutter, "The paper was enthusiastically received by fellow professionals and researchers at the conference, and I am inspired by the prospect of continuing to develop this research concept for future study." The paper itself will be published in the Organizational Development Networks journal in 2013. Perlmutter, who has an MBA in Nonprofit Management from Brandeis University's Heller School, has joined the Relational Coordination Research Collaborative as a Research & Development Specialist. Congratulations Anna and welcome on board!

A Reflection on the RCRC 2012 Roundtable:
By Sanders F. Burstein, Medical Director of Dartmouth-Hitchcock Nashua

November 10, 2012

Sanders BursteinDartmouth-Hitchcock website

On Relational Coordination: The Science of Teamwork

"Last week, Dr. Ahmed Hussain (Family Medicine, Merrimack) and I attended a conference of the 'Relational Coordination Research Collaborative', sponsored by The Dartmouth Institute for Health Policy and Clinical Practice and Brandeis' The Heller School for Social Policy and Management. RELATIONAL COORDINATION is communicating and relating for the purpose of task integration and is particularly useful for improving quality and efficiency under conditions of task interdependence, uncertainty and time constraints.   This is what we experience every day in healthcare! 

The study of Relational Coordination has shown that Effective coordination of work is carried out through frequent, timely, accurate, problem-solving communication reinforced by relationships between people who share goals, share knowledge, and have mutual respect for each other.  Studies show that the most successful teams in business or in health care have these characteristics. 

I am very proud of what we have accomplished over the last few years at D-H Nashua and when asked about the key to our success, I always respond "we have great teamwork".  As we participate in creating a sustainable health system, effective teamwork (coordination of work) will become ever more important to our success.  To the degree that we could do a better job, please think about these elements of success within your team:

Do you communicate well? Is communication:
- Frequent?
- Timely?
- Accurate?

Does communication promote problem solving (rather than blaming or conflict)?
 Does your team share:
- Goals?
- Knowledge? 
- Mutual Respect? 

Please take some time to reflect on this and share your thoughts on how your team might improve its effectiveness. Better yet, share your ideas with your team!"

Accountable Care - It's All About the Relationships - Second Annual RCRC Roundtable at Dartmouth a Big Success!

November 6, 2012

ken milneNearly 80 participants from around the US and beyond met November 2 for the second annual Relational Coordination Research Collaborative Roundtable at Dartmouth.  Starting with a keynote address by Elliott Fisher, "Accountable Care - It's All About the Relationships," we enjoyed a highly interactive day among participants who were deeply interested in the challenges of implementing high quality cost-effective care, with presenters from the eastern, midwestern and western US, Canada and Denmark who shared their innovations and insights. 

Michele Saysana of Indiana University Health explained the importance of relational coordination for her successful implementation of family centered rounds at Riley Children's Hospital.  Dominick Frosch of Palo Alto Medical Foundation showed how primary care provider teams' success with shared decisionmaking varied depending on their level of relational coordination with each other.  Karen Albertsen from Team Arbeijdsliv shared the Everyday Rehab model of home care as it is currently being rolled out across Denmark, and the importance for its success of building relational coordination among the team and with the citizen.  Joel Lazar of Dartmouth Connect described implementation of the Iora Health model of primary care and the critical importance for its success of relational coordination among the primary care team, including the wellness coach who connects directly with the patient and family.

Tony Suchman of McArdle Ramerman revealed the process of transforming conflict into teamwork through the feedback of relational coordination scores to individual clinicians.  Nancy Whitelaw and Ken Milne of Salus Global showed how relational coordination scores are being used to jumpstart conversations of interdependence and transformation in Canadian hospitals.  Finally Terry Hill of Hill Physicians Medical Group and Bill Agel of Cape Cod Health System described their use of relational coordination to diagnose the strength of relational coordination ties across delivery systems as they move toward accountable care -- with varying levels of success.

This second annual RCRC Roundtable was hosted by the Dartmouth Institute for Health Policy and Clinical Practice on behalf of the Relational Coordination Research Collaborative at Brandeis University’s Heller School for Social Policy and Management.  Facilitators for the day included Jody Hoffer Gittell (RCRC/Brandeis), Dale Collins Vidal (The Dartmouth Institute/Dartmouth Hitchcock), Gene Beyt (RCRC/Brandeis), Margie Godfrey (The Dartmouth Institute) and Craig Westling (The Dartmouth Institute).

Gittell and Vidal send their thanks to all participants, presenters, organizers and co-hosts for making the RCRC Roundtable a success.  "We have received many thanks and commendations regarding program design, content of the presentations, skillful facilitation, and especially for creating the space to have great discussions, gain new insights and build a learning community.  We hope to build on this momentum over the coming year with new and exciting lessons to share with each other next Fall!"  

Comments from participants

"I truly enjoyed the program, and can't say enough about all the thoughtful interesting people that I met." Bill Agel, Cape Cod Healthcare System 

"I had a lot of fun and look forward to continuing our work." Dominick Frosch, Palo Alto Medical Foundation Research Institute

"I am both honored and humbled to be included in such a great group of people who presented.  What fantastic and inspiring work everyone is doing!" Michele Saysana, Indiana University Health

"I really enjoyed the event. I was amazed by the high quality of discussions. I also think that the involvement of the participants was excellent. When I told Hans-Jørgen about my experiences at the meeting he said 'I am glad that you met professional, competent, kind and humorous Americans.'"  Karen Albertsen, Team Arbeijdsliv

"The RC Roundtable and Training Workshop were amazing. I feel the more I learn about RC, the more I want to know. It is a wonderful feeling. Relational Coordination affirms what my heart has known while working with groups and in organizations for years. Further, the interventional uses for RC are vast. Throughout this weekend my mind was linking concepts between your model and all of the others that I have been studying while completing my PhD. Through yours and others research on RC, a solid foundation has been laid connecting the theory with other outcome measures (safety, quality, employee satisfaction etc.) I believe the next chapter will include research on Relational Coordination's place in organizational change."  Dylan Ross, Kaiser Permanente

"Thank you for a wonderful few days of friendship and partnership in learning about RC through small group discussions and large group interactions.  I have learned so much on multiple levels."  Margorie Godfrey, The Dartmouth Institute

"Great meetings - wonderful to connect with the gang, what a great group."  Thomas Huber, Quantros

Improving Quality and Reducing Costs through Relational Coordination - Innovations from Denmark

October 2, 2012

danish regions logo.pngThe Danish Regions - entities that deliver health and human services throughout Denmark, much like the regional Strategic Health Authorities for the National Health Service in the UK - are our newest RCRC partners.  Facing the same demographic shifts and unsustainable cost trends that our partners our facing around the world, the Danish Regions have been charged with increasing the quality of care while reducing costs.  In late September, RCRC director Jody Hoffer Gittell visited with colleagues in the Capital Region and the Zealand Region who are using relational coordination together with lean to streamline work and create networks of care that center around the patient.  She heard about RC innovations that draw upon lean process improvement and social media to create shared knowledge, shared goals and mutual respect across members of the care provider team, across the care continuum and into the community.

Consider Everyday Rehab, a new approach to home care in Denmark and Sweden that engages the resident and home care worker in a partnership to improve wellness, in coordination with physicians, nurses, social workers, physical and occupational therapists. In a sense the home worker becomes a wellness coach, along the lines of the Iora Health primary care model developed by Rushika Fernandopulle in the US.

Karen Albertsen of Team Working Life in Denmark will share the Everyday Rehab model at the November 2nd Roundtable, and Joel Lazar will share the Iora Health wellness coaching model in primary care as it's being implemented at Dartmouth. Because patient engagement is foundational for delivering accountable care, we'll also hear from Michele Saysana about RC and family centered rounds at Riley Children's in Indianapolis and from Dominick Frosch about RC and shared decision-making at the Palo Alto Medical Foundation. 

Engaging Patients in Shared Decisionmaking - Key Role for Our Dartmouth Partners in New Study

September 2012

Jim WeinsteinDale VidalEveryone seems to agree that health cost and quality goals cannot be achieved without patient engagement - but how to truly engage patients given the provider focused culture of healthcare?  Our RCRC Partners at the Dartmouth Institute have been at the forefront of these efforts through their leadership in the shared decisionmaking movement.  Dale Collins Vidal (Dartmouth Institute) and Karen Sepucha (Massachusetts General Hospital) recently hosted a gathering of scholars and practitioners to move the field forward through improved measures of shared decisionmaking.  

Now Dartmouth has won a $26 million grant, together with 15 other healthcare systems in the High Value Healthcare Collaborative, from the Center for Medicare and Medicaid Innovation. Together these systems will implement a program to engage patients and implement shared decision making for patients facing hip, knee or spine surgery, and for patients with diabetes or congestive heart failure. The members of the HVHC collectively serve 50 million patients in health systems across the United States.

James N. Weinstein, CEO and President of the Dartmouth Hitchcock health system, will serve as the Principal Investigator for the grant. Dr. Weinstein started the first-in-the-nation Center for Shared Decision-Making at Dartmouth Hitchcock Medical Center and conducted the first large-scale clinical trial to incorporate the concept. Dale Collins Vidal, current Director of the Center for Shared Decision Making, will serve as the clinical innovation lead.  

“We know from our experience at Dartmouth Hitchcock that involving patients and families in their treatment decisions, with evidence-based, objective information, results in higher patient satisfaction, superior clinical outcomes, and often, lower costs,” said Weinstein. “When patients are well-informed about the risks and benefits of a test, procedure, or treatment, they have more confidence in their decisions and are more satisfied with their outcomes. Our studies have shown that the process also greatly reduces the decisional regret that can occur when patients make treatment choices without good information.”

The Dartmouth Institute serves as facilitator and data convenor for the High Value Healthcare Collaborative whose other members include Baylor Health Care System, Beaumont Health System, Beth Israel Deaconess Medical Center, Dartmouth-Hitchcock, Denver Health, Intermountain Healthcare, Mayo Clinic, North Shore–LIJ Health System, MaineHealth, Providence Health and Services, Scott and White Healthcare, Sutter Health, UCLA Health System, University of Iowa Health Care, and Virginia Mason Medical Center.  

Visitors from Denmark and Australia Explore Relational Coordination and Healthcare Transformation

June 20, 2012

The American, Danish and Australian healthcare systems are structured in fundamentally different ways. Yet all face pressure to deliver better outcomes at lower cost. Does relational coordination play a role in helping healthcare organizations around the globe meet this challenge?

To address this question, RCRC hosted a visiting delegation from Denmark and Australia on June 6 at Brandeis University’s Heller School for Social Policy and Management.  The Danish delegation included over a dozen HR Managers for local hospitals and corporate HR leaders from Region of Central Denmark led by Ditte Hughes and Joern Moerup, Directors of Corporate HR. Don Campbell, Director of General Medicine for Southern Health, represented the Australian perspective.  Hosting the visitors were Professor Jody Hoffer Gittell, Executive Director of the RCRC; Professor Stan Wallack, RCRC board member and Director of the Schneider Institutes for Health Policy; the RCRC team; and a dozen Heller Ph.D. students.

The Danish and Australian visitors presented highlights of their healthcare systems, explaining how care is paid for, organized and delivered. Both systems offer universal health insurance.  While the Danish and Australian models are distinct from each other and from the U.S. model, all three share a common challenge - overcoming silos to achieve efficient, coordinated care. Wallack argued that "only when professionals work collaboratively within and across institutions will health systems be able to achieve consistently high-quality, patient-centered care."  

Three Heller Ph.D. students presented new research on relational coordination. Signe Peterson Flieger presented early results on relational coordination as a characteristic of effective Patient-Centered Medical Homes.  Lynn Garvin described how relational coordination concepts will inform measures of meaningful use or "ideal use" of personal health records and patient-clinician secure messaging for the Veterans Administration.  Saleema Moore shared early findings on the strengths and weaknesses of existing networks for coordinating diabetes care, using network analysis of relational coordination and social network data. 

The Danish delegates also visited Brigham and Women's, Beth Israel Deaconess, and Massachusetts General Hospital during their week in Boston while the Australian delegate attended Professor Clay Christiansen's workshop at Harvard Business School.  The visit to RCRC followed multiple trips by Gittell to Denmark over the past two years to speak on the topiic of relational coordination, and an international fellowship earlier this year to Australia on the role of relational coordination in transforming primary healthcare.  RCRC currently has three partners in Denmark, one in Australia, one in Canada and one in Japan, as well as faculty and student partners around the world.  According to Gittell, “We anticipate additional partners in these countries and from across Europe and Asia, given growing interest in relational coordination as a tool to improve performance in healthcare and beyond.”  

Curt Lindberg of Complexity Partners wins the Best Paper of the Year award for Organizational Development and Change

curt-lindberg-photoJune 1, 2012

"Leadership in a Complex Adaptive System: Insights from Positive Deviance" by Curt Lindberg (Billings Clinic, Complexity Partners) and Marguerite Schneider (New Jersey Institute of Technology) was selected as the best paper of the year by the Organizational Development and Change Division.  The paper will be presented Tuesday August 7 from 9:45-11:15 in the Liberty Ballroom B, Sheraton Boston Hotel.  

Curt is the most recent partner to join the Relational Coordination Research Collaborative, and has begun to use RC in his work with the Billings Clinic.  As a founder of the Plexus Institute, Curt pioneered applications of complexity science to health and human services.  He co-authored/co-edited several influential books including Edgeware: Insights from Complexity Science for Health Care Leaders and On the Edge: Nursing in the Age of Complexity.  Please find his bio posted here and an abstract of his paper posted here.

Bo Vestergaard of Act2Learn wins a Best Paper award for Management Consulting

Bo photoMay 16, 2012

"Leading Unpopular Changes with Fair Process: Towards a Strategic Process Design" by Bo Vestergaard of Act2Learn (Denmark) was selected as one of the top papers submitted for the upcoming AOM meetings in Boston, by the Management Consulting division.  This paper will be presented Monday August 6 from 1:15-2:45 in the Adams Room of the Westin Copley Place, in Boston.  

Bo asks:  "How do you transform unpopular changes - demands to produce more, at higher quality, using less resources – into frontline innovation?  Most managers intuitively buy in to my argument of why relational coordination is a driver of quality and efficiency outcomes for core work processes.  From research we know we are likely to achieve both outcomes if we focus on increasing RC.  But how we do it matters.  By following – or violating - the principles of fair process, top, middle, and frontline managers are more or less likely to succeed in engaging the frontline in delivering solutions that realize the strategy and increase performance outcomes.”   In other words, as a leader or change agent, you have to be the change you want to create.  Fair process is what we could also call relational process - acting to build shared goals and shared knowledge in a mutually respectful way.

Bo is one of the launch partners for RCRC in Denmark, using relational coordination to improve effectiveness in health and human service organizations, as well as manufacturing.  His organization - Act2Learn - is planning to sponsor the next RC Training Workshop in Copenhagen, September 24-25.  If you attend the AOM meetings in Boston this August, you can meet Bo and his Act2Learn colleagues at the RCRC reception Saturday evening, August 4 from 7:30-9:00, and attend his presentation on Monday.  An abstract of the paper is posted here.

Palo Alto Medical Foundation Awarded PCORI Grant to Study Patient Centered Care and Relational Coordination

Frosch photoMay 8, 2012

Led by Dominick Frosch of the Palo Alto Medical Foundation, this study is titled "Creating a Zone of Openness to Increase Patient-Centered Care." The two novel interventions to be implemented and tested are hypothesized to impact specific processes during the clinical consultation which in turn impact the outcomes of patient activation, empowerment, increased collaborative engagement in clinical decision making and patient perceptions of being informed and satisfied with the care received. An important innovation is the clear recognition that the interventions will be embedded in existing microsystems that must be analyzed and understood to ensure that the implementation approach is responsive to the local environment and workflow logistics.

A further innovation is that the study will also examine the relationship between the interventions and relational coordination among clinical staff in participating clinics. Developed as a way to understand organizational performance and improvement, relational coordination is “a mutually reinforcing process of communication and relation for the purpose of task integration.” A professional team that shows high levels of relational coordination can identify a shared goal (e.g., providing outstanding patient care) and has mutual respect for the roles each team member plays in achieving this goal. Initially developed in the context of the airline industry, relational coordination is increasingly being applied in health care settings as an approach to facilitating organizational change. The concepts are philosophically consistent with patient centered care. The study will measure the degree of relational coordination among clinical teams to examine if it is associated with better patient outcomes and will also measure whether the interventions reciprocally lead to greater relational coordination among clinical teams.  For more about this proposal, visit here.  For the Health Affairs article that lays the groundwork for this research, visit here.

Jane DuttonExploring Positive Relationships at WorkJoin Us in Welcoming Professor Jane Dutton to the RCRC Board

April 3, 2012

RCRC welcomes Jane E. Dutton, Ph.D. as a new member of the Board, approved unanimously by our current board members to fill the seat recently vacated by Edgar Schein.  MIT Professor Emeritus Ed Schein was a powerful influence in the founding of RCRC and has now stepped down to prepare his memoirs.  Professor Dutton is a leader in the field of relationships at work who will bring this perspective to the RCRC, with an appeal to both practitioners and researchers.  She is the Robert Kahn Distinguished University Professor of Business Administration and Psychology at the Ross School of Business, University of Michigan.  Her research is focused on processes that build capabilities and strengths of employees in organizations.  In particular, she examines how high quality connections and identity processes increase employees' and organizations' capabilities.  Her research has explored compassion and organizations, resilience and organizations, as well as energy and organizations. This research stream is part of a growing domain of expertise at the University of Michigan called Positive Organizational Scholarship  Her past research has explored processes of organizational adaptation, focusing on how strategic issues are interpreted and managed in organizations, as well as issues of organizational identity and change.

Read more here

On Doctors and Other Divas

1. Skill or service or efficiency is not concerned with empathy or relating.

2. Not only is skill or service or efficiency not concerned with empathy or relating, they are in contradistinction; more of one guarantees less of the other.

3. Empathy or relating is a “nice-to-have”; it’s the icing on top but makes no appreciable (read, measurable) difference in the execution of a skill or service, nor in the world generally.

There’s also a fourth underlying assumption which Seth Godin notes (how great is this guy? Posts seven days a week, produces potent little gems most):

4. Trapped in the “scarcity model” of thinking, we assume if someone is truly gifted they don’t have the “time or focus to also be kind or reasonable or good at understanding our needs”. In short, a “diva” is great because she is a jerk.

All these types of assumptions are markers of the “scarcity model” of thinking, the conception of the world in which everything is finite. They are also markers of a conception of the world in which a fatuously mechanistic cause-and-effect operates.

It’s all nonsense, all a fundamental delusion about the world and the way it works, and people like Professor Jody Hoffer Gittell are illustrating it.

Read more here 

Touchy Feely? Get Over it!  Dr. Tony Suchman Blogs about Jody Hoffer Gittell and Relational Coordination 

April 13, 2012     

Dr. Tony Suchman, McCardle Ramerman Center website        

Tony SuchmanBrandeis University researcher Jody Hoffer Gittell has been making sense of how people work together effectively for most of her life. She grew up on a farm where there was constant work with many interdependent tasks. Even at that young age she found it striking that everyone knew what needed to be done and how to coordinate their work with everyone else’s.

More than defining RC, Jody identified specific qualities of communication and relationship that made this possible and designed the elegantly simple Relational Coordination Survey to measure them. She found that on high performing teams members share the same goals, know about each other’s work and respect each other’s work. 

Read the blog post here

Developing Relational LeadershipCarsten Hornstrup

New Book:  Developing Relational Leadership

by RCRC partner Carsten Hornstrup and colleagues

March 5, 2012

Taos Institute Publications

Taos Institute Publications is thrilled to offer this innovative book which has been translated from Danish to English. The authors share a wealth of experiences working with leadership and change in organizations.

"Developing Relational Leadership offers the scholar, the practitioner, and most importantly, the scholar-practitioner an exuberance of riches. The authors provide a deep foray into the worlds of systemic, cybernetic and constructionist ideas, while bringing those ideas to the worlds of leadership and organizational change and practice. The authors share cases that present tools for exploring these ideas and practices..."  

Read more here

Relational Coordination: Harnessing the Transformative Power of Relationships to Improve VA Health Care

November 2011

Richard M. Frankel, Ph.D.

Excerpted from The Richard L. Roudebush VA HSR&D Center of Excellence on Implementing Evidence-Based Practice

US Department of Veteran Affairs website

One promising research approach to transforming performance within and across settings is "relational coordination," a term coined by Jody Gittell, a professor of management at Brandeis University. Relational coordination refers to, "a mutually reinforcing process of interaction between communication and relationships carried out for the purpose of task integration." Gittell first applied the concept to studying Southwest Airlines and found that the company’s success lay primarily in its ability to encourage and support high levels of communication across multiple job classifications and management. Her latest work has been in health care where she has shown that organizations with high levels of relational coordination have better care outcomes and lower overall costs.

...Relational coordination is not about blaming individuals for poor performance, but rather encouraging us to recognize the immense complexity of creating coordinated experiences for the billion patient visits in the United States each year. Doing so requires everyone’s best collective efforts and creativity; to do less may put the future of patients like Mr. LW, and our current medical culture, at risk.

Read the complete article here

Transforming Relationships for High Performance

November 4, 2011 

The Center for Positive Organizational Scholarship Newsletter
Excerpted from The Center for Positive Organizational Scholarship website

Perhaps what is most intriguing about the Collaborative (RCRC) is the use of quantitative methodologies to measure and map the highly qualitative processes of relational coordination and organizational change. We are developing methods—like relationship mapping—that help to make relational dynamics visible to participants for the purpose of establishing the current state, then reflecting on it and transforming it as part of a broader intervention. Other methods may be useful for assessing the effectiveness of interventions, for example, using pre-and post-intervention measures of relational coordination.

Relational coordination theory contributes to POS by making visible the humanistic process underlying the technical process of coordination, showing that coordination encompasses not only the management of interdependence between tasks, but also between the people who perform the tasks.

Read the complete article here

Australian Primary Health Care Research Institute Awards Jody Hoffer Gittell International Visiting Fellowship

Awarded through:

Lucio Naccarella - Australian Health Workforce Institute, University of Melbourne
Greg Bamber - Department of Management, Faculty of Business and Economics, Monash University
David Burns - Affinity Organisational Development

Excerpted from the Australian Health Workforce Institute website 

Prof. Jody Hoffer Gittell's work and research experience has direct relevance to the Australian PHC service system, which is facing pressures due to increasing demands from an ageing population, increasing chronic disease, increasing co-morbidities, workforce shortages, and increasing health system complexity and fragmentation. To improve access to care, to enhance local service coordination, population health planning and service integration, the Australian Government is establishing a network of independent PHC organisations (PHCOs/ Medicare Locals) National Health and Hospitals Reform Commission (NHHRC).

Dr Gittell's work has clearly shown that policy changes and increased access to care will not alone address these pressures. Timely, accurate, problem-solving communication that crosses all organisational boundaries is required to build a high performing work system that foster relational coordination across multidisciplinary primary health care team.

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