Jody Hoffer Gittell The Heller School for Social Policy and Management Brandeis University

1. Front Line Workers and the Coordination of Care Jody Hoffer Gittell The Heller School for Social Policy and Management Brandeis University Cornell Healthcare Conference Delivery System Reforms and Implications for the Workforce May 11-12, 2010

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

3. Findings Found that relationships shape the communication through which coordination occurs ...

4. For better… Relationships Shared goals Shared knowledge Mutual respect Communication Frequent Timely Accurate Problem-solving

5. …or for worse Relationships Functional goals Exclusive knowledge Lack of respect Communication Infrequent Delayed Inaccurate Blaming

6. This process is called relational coordination coordinating work through relationships of shared goals, shared knowledge and mutual respect

7. Investigated performance effects of relational coordination • Nine site study of flight departures over 12 months of operation at Southwest, American, Continental and United • 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 • Measured quality and efficiency performance, adjusting for product differences

8. Relational coordination and flight departure performance SWA1 UNI3 SWA2 Relational coordination CON1 UNI1 UNI2 CON2 AMR1 AMR2 Quality/efficiency performance index

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

10. Commonwealth Fund report “The most common quality problems reported by physicians are related to problems of coordination.”

11. 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.”

12. 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.” -Physician leader, Brigham & Women’s Hospital

13. 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.” - Nurse leader, Massachusetts General Hospital

14. Investigated performance effects of relational coordination • Followed joint replacement patients in 9 high volume hospitals in New York, Massachusetts and Texas (n=878) • Measured relational coordination among doctors, nurses, physical therapists, social workers and case managers (n=332) • Measured efficiency and quality performance, adjusting for patient characteristics and surgical volume

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

16. Findings extended in other healthcare settings • Medical units at Newton-Wellesley Hospital • Chronic care at Cambridge Health Alliance • Chronic care in California multi-specialty group • Nursing homes in Massachusetts • All units in Pennsylvania rural hospitals • Relational coordination also enhances care provider outcomes • Increases job satisfaction • Reduces burnout • Reduces emotional exhaustion

17. Relational coordination enables organizations to push out the quality/efficiency frontier while enhancing working conditions for care providers Quality Relational coordination Efficiency

18. There are other responses to coordination challenges • Reengineering • Total quality management • “Lean” strategies • Redesigning work flows from patient’s point of view

19. But addressing technical issues is often 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.” -- CMO, Tenet Healthcare Systems

20. Why does relational coordination work? Relational coordination may provide the cultural or relational underpinnings for process improvement or “lean” strategies

21. Why does relational coordination work? Relationships of shared goals, shared knowledge and mutual respect enable providers to form a common identity across functional and organizational boundaries Allowing them to coordinate work “on the fly” and improve over time

22. How can healthcare organizations strengthen relational coordination?

23. High Performance Work System Strengthening relational coordination Select for teamwork Measure team performance Quality Performance Reward team performance Relational Coordination Communication Frequent Timely Accurate Problem-solving Relationships Shared goals Shared knowledge Mutual respect Resolve conflicts proactively Invest in frontline leadership Efficiency Performance Design jobs for focus Make job boundaries flexible Support boundary spanners Job Satisfaction Connect through pathways Broaden participation in patient rounds Develop shared info systems Partner with suppliers

24. A high performance work system • These work practices are all cross-cutting, strengthening connections across the silos that typically divide health care providers • Together they form a unique type of high performance work system, focused on cross-functional coordination • This high performance work system • increases quality and efficiency performance • increases employee satisfaction, professional efficacy, reduces turnover, burnout • also likely to increase employee engagement – why?

25. Work Practices Connect All Care Providers Around Patient Case Managers Attending Physicians Nurses Physical Therapists Nursing Assistants Patient Social Workers Technicians Referring Physicians Residents

26. High Performance Work System Positive effects on performance outcomes Select for teamwork Measure team performance Quality Performance Reward team performance .26*** Relational Coordination Communication Frequent Timely Accurate Problem-solving Relationships Shared goals Shared knowledge Mutual respect Resolve conflicts proactively Invest in frontline leadership .33*** .44*** Efficiency Performance Design jobs for focus Make job boundaries flexible Support boundary spanners .17** Job Satisfaction Connect through pathways Broaden participation in patient rounds Develop shared info systems Partner with suppliers

27. Challenges going forward • Management/labor challenge • How to implement this “systems” approach? • What are the likely obstacles? • Policy challenge • Which policies will help to support this “systems” approach? • Which policies will undermine it?

29. Bibliography Gittell, J.H. (2009). High Performance Healthcare: Using the Power of Relationships to Achieve Quality, Efficiency and Resilience. New York: McGraw-Hill. Gittell, J.H., Seidner, R.B., Wimbush, J. (2010). “A Relational Model of How High Performance Work Systems Work,” Organization Science, forthcoming. Gittell, J.H., Weinberg, D., Bennett, A., Miller, J.A. (2008). “Is the Doctor In? Impact of Job Design on Relational Coordination and Performance,” Human Resource Management, 47(4): 729-755.  Gittell, J.H. (2008). “Relationships and Resilience: Care Provider Responses to Pressures from Managed Care,” Journal of Applied Behavioral Science, 44(1): 25-47.  Gittell, J.H., Weinberg, D.B., Pfefferle, S., Bishop, C. (2008). “Impact of Relational Coordination on Job Satisfaction and Quality Outcomes: A Study of Nursing Homes,” Human Resource Management Journal, 18(2).  Gittell, J.H., Weiss, L. (2004). “Coordination Networks Within and Across Organizations: A Multi-Level Framework,” Journal of Management Studies, 41(1): 127-153.  Gittell, J.H. (2003). The Southwest Airlines Way: Using the Power of Relationships to Achieve High Performance. New York: McGraw-Hill.  Gittell, J.H. (2002). “Coordinating Mechanisms in Care Provider Groups: Relational Coordination as a Mediator and Input Uncertainty as a Moderator of Performance Effects,” Management Science, 48(11): 1408-1426. Gittell, J.H. (2002). “Relationships between Service Providers and their Impact on Customers,” Journal of Service Research, 4(4): 299-311. Gittell, J.H., Fairfield, K., et al (2000). “Impact of Relational Coordination on Quality of Care, Post-Operative Pain and Functioning, and Length of Stay: A Nine Hospital Study of Surgical Patients,” Medical Care, 38(8): 807-819. Havens, D.S., Gittell, J.H., Vasey, J., Lin, W.T. (2010). “Relational Coordination Among Nurses and Other Disciplines: Impact on the Quality of Patient Care,” Journal of Nursing Management, under review. Ryan, M., Gittell, J.H. (2010). "Relational Coordination Between Patients and their Primary Care Providers:  Impact on Satisfaction and Clinical Outcomes," under preparation. Weinberg, D.B., Lusenhop, W., Gittell, J.H., Kautz, C. (2007). “Coordination between Formal Providers and Informal Caregivers,” Health Care Management Review, 32(2): 140-150.