Learning to Coordinate: A Relational Model of Organizational Change

1. Learning to Coordinate: A Relational Model of Organizational Change Jody Hoffer Gittell, Brandeis University Amy Edmondson, Harvard Business School Edgar Schein, MIT Sloan School of Management 2011 Academy of Management San Antonio, TX

2. Learning to coordinate • Coordination is akey organizational competence that drives performance • But how do organizations learn to coordinate? • If coordination is relational, people need to learn new patterns of interrelating • How does this happen in an intentional way? • What is the sequencing or interplay between changing relationships, and changing the structures that reinforce them?

3. In this paper we will… • Explore relational models of • Coordination • Learning and change • Propose a relational model of learning to coordinate • Describe three cases of learning to coordinate • Canadian obstetrics units • Texas primary care clinics • Maine health and human services

4. Relationships shape the communication through which coordination occurs Frequent communication Timely communication Accurate communication Problem-solving communication Shared goals Shared knowledge Mutual respect

5. This process is called relational coordination “A mutually reinforcing process of communicating and relating for the purpose of task integration” (Gittell 2011)

6. How do organizations learn new ways to coordinate? • Because relational coordination is a mutually reinforcing process, it is difficult to change • Relational dynamics tend to become deeply embedded in the form of assumptions and self-concepts • What do we know about organizational learning and change that might be helpful?

7. Organizational learning (Edmondson 2002) • Organizational learning is interpersonal and relational, and often involves learning to coordinate work in a new way • Psychological safety – the perception that it is safe to express disagreement and be fallible – is a necessary condition for this kind of interpersonal, relational learning to occur • Psychological safety enables participants to identify and question current assumptions

8. Changing structures is not enough • Change cannot occur only through changing formal structures – new structures will not be embraced or sustained unless the assumptions that underlie them are identified and questioned (Fletcher, Bailyn, Blake-Beard 2009) • Need ‘discursive’ or ‘relational’ space for identifying and questioning the current organizational assumptions (Fletcher, Bailyn, Blake-Beard 2009; Kellogg 2009)

9. How to start the learning process (Schein 2010) • Individuals or groups can participate in a ‘cultural island’ that enables examination of past practices, cultural norms and constraints to learning • Goal is to identify and commit to shared goals based on a new compact with the organization and with each other • This can improve relational coordination

10. Off-site agenda: Learning and unlearning (Schein 2010) • Step 1: Self-assessment of present state • Step 2: Identification of learning barriers • Step 3: Identification of cultural constraints and aides • Step 4: Commitment process to shared goals and compact • Step 5: Identification of desired new behaviors • Timely and relevant communication • Role-mapping and identification of interdependence • Role negotiation to build relationship • Mutual sharing of knowledge • Mutual agreement on how to measure progress • Step 6: Ensure that rewards and incentive systems and other organizational structures are consistent with the new ways of working

11. Learning to coordinate: A relational model of organizational change Relational coordination Shared goals Shared knowledge Mutual respect Frequent communication Timely communication Accurate communication Problem-solving comm Organizational structures Performance Relational intervention Cultural island Psychological safety Relationship mapping Role modeling

12. Case studies of learning to coordinate • Case 1: Canadian obstetrics • Case 2: Texas primary care • Case 3: Maine health and human services

13. Canadian obstetrics • Canadian obstetrician and obstetrics nurse discovered through their own work experience that relational approaches between providers and with patients seemed to result in fewer errors, better quality outcomes, less waste, fewer liability claims • With support from a Canadian insurance association, they formed a consulting practice to teach their methods to obstetrics units throughout the country

14. Canadian obstetrics (continued) • Intervention works with frontline providers to improve work processesand relational dynamics, then seeks leadership support for new structures to support the new relational dynamics • “We didn’t know what to call what we were doing, but after reading organizational theory in the late 1990s, Irealized we were doing relational coordination” (Ken Milne, CEO, Salus Global Consulting)

15. Canadian obstetrics (continued) • Have worked with over 100 Canadian hospitals and about 30 U.S. hospitals, often achieving reductions in liability claims, and increases in satisfaction and other quality outcomes • Now rolling out the model to other hospital units (surgery, ER, ICU), that have been requesting the same type of intervention

16. Texas primary care • Research team from UT Health Science Center in San Antonio enrolled 40 rural primary care clinics in an effort to improve chronic care for their patients • Intervention team led by a physician/researcher helped clinics to measure their outcomes, their structures for chronic care delivery, as well as relational coordination and reciprocal learning

17. Texas primary care (continued) • Through coaching visits every 2-3 weeks over a one year period, the intervention team facilitated meetings, process improvement efforts and relational improvements among clinical and non-clinical members • “We shared the data with them and let them decide what they wanted to do about it. We gave advice, like meeting with each other, doing regular huddles to coordinate care – but we were there to help them do what they wanted to do” (Raquel Romero, MD, Intervention Team Leader)

18. Texas primary care (continued) • Base-line cross-sectional data suggests that relational coordination and reciprocal learning among members predict greater adoption of chronic care structures • Still analyzing longitudinal data to assess changes over time

19. Maine Dept. of HHS • Leaders in Maine’s Office of Lean Management have been implementing lean principles in government for 6 years • They respond to requests for training and for assistance with process changes

20. Maine Dept. of HHS (continued) • “It is a blame/shame environment. During the training we started to see the goal alignment, the shared knowledge and the respect they were developing for each other. We saw it but didn’t know what it was” (Walter Lowell, Director, Office of Lean Management) • “We realized that when the lean training works, it’s because they are changing their relationships in really important ways” (ibid)

21. Maine Dept. of HHS (continued) • “We designed a coaching intervention to foster relational coordination, and we call it the soft side of lean” (Kelly Grenier, Consultant, Office of Lean Management) • “But people can get really discouraged when they go back to work – some say it was great training but within a couple of months they are back in their old boxes. Nothing has changed to support their new ways of working together” (ibid)

22. Learning from cases • In cases 1 and 2, relational interventions were followed by changes in organizational structures • Our model predicts these structures will reinforce and sustain the new relational patterns • In case 3, relational interventions were not followed by changes in organizational structures • Our model predicts failure to sustain new relational patterns • In all three cases, relational interventions occurred along with process improvement interventions • We revised our model to reflect this combined intervention

23. Learning to coordinate: A relational model of organizational change Relational coordination Shared goals Shared knowledge Mutual respect Frequent communication Timely communication Accurate communication Problem-solving comm Organizational structures Performance Relational intervention Cultural island Psychological safety Relationship mapping Role modeling Process improvement intervention Data gathering/analysis Process mapping Structured problem solving