Relational coordination and team‐based care: Change initiative overload and other challenges in a learning health system

Burns L.R., Nembhard I.M., Shortell S.M.

Healthcare policy in the United States (U.S.) has focused on promoting integrated healthcare to combat fragmentation (e.g., 1993 Health Security Act, 2010 Affordable Care Act). Researchers have responded by studying coordination and developing typologies of integration. Yet, after three decades, research evidence for the benefits of coordination and integration are lacking. We argue that research efforts need to refocus in three ways: (1) use social networks to study relational coordination and integrated healthcare, (2) analyze integrated healthcare at three levels of analysis (micro, meso, macro), and (3) focus on clinical integration as the most proximate impact on patient outcomes. We use examples to illustrate the utility of such refocusing and present avenues for future research. • Integration research should consider process models, networks, and multi-level analysis. • The process model examines relational coordination (e.g., information exchange). • Networks examine size, centrality, density, tie strength, embeddedness, & brokers. • Multi-level analysis encompasses micro, meso, and macro levels.

Connelly B., Battaglia C., Gilmartin H.M.

Large healthcare institutions like the Veterans Health Administration (VA) continually seek best practices to improve clinical care. Relational coordination is an evidence-based organizational theory of communicating and relating to coordinate work and drive performance outcomes. Implementing relational coordination-guided practices can be difficult due to challenges with spreading information across large systems. Using social marketing theory and evidence-based dissemination strategies, we developed an evidence-based dissemination plan to educate and motivate researchers and operational staff to study and implement relational coordination in the VA. In this case study, we used the four Ps (product, price, place, promotion) of social marketing theory to develop a 2-phase dissemination strategy. In phase one, we created and distributed relational coordination information and invited VA staff to join the Relational Coordination Research Collaborative. In phase two, dissemination efforts targeted researchers ready to implement relational coordination within existing programs of research. Process and outcome measures included dissemination, engagement and adoption data and a post-project survey. Quantitative results were calculated using descriptive statistics. Survey text responses were analyzed using deductive content analysis and a structured categorization matrix. Phase one included social media dissemination, virtual and in-person presentations, as well as phone and email communication between project staff and the target audience. In total, 47 VA staff became members of the Relational Coordination Research Collaborative and 27 routinely participated in online research seminars. In phase 2, 13 researchers expressed interest in studying relational coordination and 5 projects were selected to participate. Multiple relational coordination-related trainings and publications originated from this program. Dissemination approaches that involved personalized, one-on-one efforts (e.g., phone or email) seemed to be more effective at disseminating relational coordination compared to social media or online presentations. Participants in phase 2 agreed that relational coordination should be adopted in the VA but indicated that cost would be a barrier. Results support the importance of evidence-based dissemination planning that address the unique costs and benefits of programs.

Thygeson N.M., Logan C., Lindberg C., Potts J., Suchman A., Merchant R., Thompson R.

Bolton R., Logan C., Gittell J.H.

Work is increasingly complex, specialized, and interdependent, requiring coordination across roles, disciplines, organizations, and sectors to achieve desired outcomes. Relational coordination theory proposes that relationships of shared goals, shared knowledge, and mutual respect help to support frequent, timely, accurate, problem-solving communication, and vice versa, enabling stakeholders to effectively coordinate their work across boundaries. While the theory contends that cross-cutting structures can strengthen relational coordination, and that relational coordination promotes desired outcomes for multiple stakeholders, the empirical evidence supporting the theory has not previously been synthesized. In this article, we systematically review all empirical studies assessing the predictors and outcomes of relational coordination published from 1991 to 2019. We find evidence supporting the existing theory and discuss how that evidence supports expanding the theory from a linear structure–process–outcomes model to a dynamic model of change. An agenda for researchers and practitioners is proposed.

Tørring B., Gittell J.H., Laursen M., Rasmussen B.S., Sørensen E.E.

In surgical teams, health professionals are highly interdependent and work under time pressure. It is of particular importance that teamwork is well-functioning in order to achieve quality treatment and patient safety. Relational coordination, defined as “communicating and relating for the purpose of task integration,” has been found to contribute to quality treatment and patient safety. Relational coordination has also been found to contribute to psychological safety and the ability to learn from mistakes. Although extensive research has been carried out regarding relational coordination in many contexts including surgery, no study has explored how relational coordination works at the micro level. The purpose of this study was to explore communication and relationship dynamics in interdisciplinary surgical teams at the micro level in contexts of variable complexity using the theory of relational coordination. An ethnographic study was conducted involving participant observations of 39 surgical teams and 15 semi-structured interviews during a 10-month period in 2014 in 2 orthopedic operating units in a university hospital in Denmark. A deductively directed content analysis was carried out based on the theory of relational coordination. Four different types of collaboration in interdisciplinary surgical teams in contexts of variable complexity were identified representing different communication and relationship patterns: 1) proactive and intuitive communication, 2) silent and ordinary communication, 3) inattentive and ambiguous communication, 4) contradictory and highly dynamic communication. The findings suggest a connection between communication and relationship dynamics in surgical teams and the level of complexity of the surgical procedures performed. The findings complement previous research on interdisciplinary teamwork in surgical teams and contribute to the theory of relational coordination. The findings offer a new typology of teams that goes beyond weak or strong relational coordination to capture four distinct patterns of relational coordination. In particular, the study highlights the central role of mutual respect and presents proposals for improving relational coordination in surgical teams.

Falatah R., Conway E.

To examine the association between relational coordination, job satisfaction, affective commitment and turnover intention.While there is a substantial body of literature that examines how relational coordination influences outcomes among nurses in western societies, there is no known study that examines the impact of relational coordination on outcomes in a non-western health care system. As many of the factors associated with nursing turnover in Saudi Arabia are uniquely complex and challenging, a focus on relational coordination in this context is particularly worthy of investigation.The study utilized a cross-sectional online survey. A total of 180 nurses participated in the study.The results indicated that the relationship between relational coordination and turnover intention is mediated by job satisfaction. The results further show that the relationship between relational coordination and turnover intention is mediated by affective commitment.High levels of relational coordination can give rise to various outcomes of relevance to nurses, allied health professionals and patients.Reconfigured job designs to build and cultivate links between nurses and other clinical disciplines will be necessary to enhance job satisfaction and commitment levels and to reduce turnover intention.

Abu-Rish Blakeney E., Lavallee D.C., Baik D., Pambianco S., O’Brien K.D., Zierler B.K.

Hustoft M., Biringer E., Gjesdal S., Aβmus J., Hetlevik Ø.

Rehabilitation services depend on competent professionals who collaborate effectively. Well-functioning interprofessional teams are expected to positively impact continuity of care. Key factors in continuity of care are communication and collaboration among health care professionals in a team and their patients. This study assessed the associations between team functioning and patient-reported benefits and continuity of care in somatic rehabilitation centres. This prospective cohort study uses survey data from 984 patients and from health care professionals in 15 teams in seven somatic rehabilitation centres in Western Norway. Linear mixed effect models were used to investigate associations between the interprofessional team communication and relationship scores (measured by the Relational Coordination [RC] Survey and patient-reported benefit and personal-, team- and cross-boundary continuity of care. Patient-reported continuity of care was measured using the Norwegian version of the Nijmegen Continuity Questionnaire. The mean communication score for healthcare teams was 3.9 (standard deviation [SD] = 0.63, 95% confidence interval [CI] = 3.78, 4.00), and the mean relationship score was 4.1 (SD = 0.56, 95% CI = 3.97, 4.18). Communication scores in rehabilitation teams varied from 3.4–4.3 and relationship scores from 3.6–4.5. Patients treated by teams with higher relationship scores experienced better continuity between health care professionals in the team at the rehabilitation centre (b = 0.36, 95% CI = 0.05, 0.68; p = 0.024). There was a positive association between RC communication in the team the patient was treated by and patient-reported activities of daily living benefit score; all other associations between RC scores and rehabilitation benefit scores were not significant. Team function is associated with better patient-reported continuity of care and higher ADL-benefit scores among patients after rehabilitation. These findings indicate that interprofessional teams’ RC scores may predict rehabilitation outcomes, but further studies are needed before RC scores can be used as a quality indicator in somatic rehabilitation.

Bolinger A.R., Klotz A.C., Leavitt K.

To function optimally, most workgroups need an interdependent mix of members in strategically core and noncore roles who work effectively together. However, whereas researchers have investigated the contributions of star performers and strategically core group members, relatively little is known about individuals in noncore roles and how they may facilitate group functioning and contribute to the relational climate of organizations. In this paper, we develop a multi-level, bottom-up model that explains two paths through which employees in noncore roles facilitate the dissemination of relational coordination in organizations. We leverage insights from self-categorization theory and relational coordination theory to explain different ways in which noncore role incumbents attempt to enact their noncore role identities. Then, we describe how the relational stances of those occupying core roles can enable or hinder the identity validation of those in noncore roles, and how validating the role-based identities ...

Caldwell N.D., Roehrich J.K., George G.

Public-private collaborations, or hybrid organizational forms, are often difficult to organize because of disparate goals, incentives, and management practices. Some of this misalignment is addressed structurally or contractually, but not the management processes and practices. In this study, we examine how the coordination of these social and work relationships, or relational coordination, affects task performance and the creation of social value. We employ a dyad perspective on two long-term relationships that are part of a wider ecosystem. We illustrate the social value creation process, identifying mutual knowledge and goal alignment, as necessary to create relational coordination. We find that the degree of professional embeddedness moderates the link between coordination and task performance, and explore the role that organizational and ecosystem experiences play. We develop a model of how relational coordination influences social value creation in hybrids. The findings have implications for social value creation, hybrid collaborations, and organizational design. This article is protected by copyright. All rights reserved.

Mueller S.K., Schnipper J.L., Giannelli K., Roy C.L., Boxer R.

Dispersion of inpatient care teams across different medical units impedes effective team communication, potentially leading to adverse events (AEs).To regionalize 3 inpatient general medical teams to nursing units and examine the association with communication and preventable AEs.Pre-post cohort analysis.A 700-bed academic medical center.General medicine patients on any of the participating nursing units before and after implementation of regionalized care.Regionalizing 3 general medical physician teams to 3 corresponding nursing units.Concordance of patient care plan between nurse and intern, and adjusted odds of preventable AEs.Of the 414 included nurse and intern paired surveys, there were no significant differences pre- versus postregionalization in total mean concordance scores (0.65 vs 0.67, P = 0.26), but there was significant improvement in agreement on expected discharge date (0.56 vs 0.68, P = 0.003), knowledge of the other provider's name (0.56 vs 0.86,P < 0.001), and daily care plan discussions (0.73 vs 0.88, P < 0.001). Of the 392 reviewed patient medical records, there was no significant difference in the adjusted odds of preventable AEs pre- versus postregionalization (adjusted odds ratio: 1.37, 95% confidence interval: 0.69, 2.69).We found that regionalization of care teams improved recognition of care team members, discussion of daily care plan, and agreement on estimated discharge date, but did not significantly improve nurse and physician concordance of the care plan or reduce the odds of preventable AEs. Our findings suggest that regionalization alone may be insufficient to effectively promote communication and lead to patient safety improvements. Journal of Hospital Medicine 2016;11:620-627. © 2016 Society of Hospital Medicine.

Hoffer Gittell J.

Stein J., Payne C., Methvin A., Bonsall J.M., Chadwick L., Clark D., Castle B.W., Tong D., Dressler D.D.

Cramm J.M., Twisk J., Nieboer A.P.

This study aimed to identify the relationships of self-management abilities and frailty to perceived poor health among community-dwelling older people in the Netherlands while controlling for important individual characteristics such as education, age, marital status, and gender. The cross-sectional study sample consisted of 869/2212 (39% response rate) independently living older adults (aged ≥70 years) in 92 neighborhoods of Rotterdam. In the questionnaires we assessed self-rated health, frailty using the Tilburg Frailty Indicator (TFI) and self-management abilities with the short version of the Self-Management Ability Scale (SMAS-S). We first used descriptive analysis to identify those in poor and good health. Differences between groups were established using chi-squared and t-tests. Relationships between individual characteristics, frailty, self-management abilities and poor health were investigated with correlation analyses. Multilevel logistic regression analyses were than performed to investigate the relationships of self-management abilities and frailty to health while controlling for age, gender, education, and marital status. The results of the multilevel regression analyses are reported as odd ratios. Respondents in poor health were older than those in good health (78.8 vs. 77.2; p ≤ .001). A significantly larger proportion of older people in poor health were poorly educated (38.4% vs. 19.0%; p ≤ .001) and fewer were married (33.6% vs. 46.3%; p ≤ .001). Furthermore, older people in poor health reported significantly lower self-management abilities (3.5 vs. 4.1; p ≤ .001) and higher levels of frailty (6.9 vs. 3.3; p ≤ .001). Correlation analyses showed significant relationships between frailty, self-management abilities and poor health. Multilevel analyses showed that, after controlling for background characteristics, self-management abilities were negatively associated with poor health (p ≤ .05) and a positive relationship was found between frailty and poor health (p ≤ .05) among older people in the community. Self-management abilities and frailty are important for healthy aging among community-dwelling older people in the Netherlands. Particularly vulnerable are the lower educated older adults. Interventions to improve self-management abilities may help older people age healthfully and prevent losses as they age further.

Valentine M.A., Nembhard I.M., Edmondson A.C.

Teamwork in health care settings is widely recognized as an important factor in providing high-quality patient care. However, the behaviors that comprise effective teamwork, the organizational factors that support teamwork, and the relationship between teamwork and patient outcomes remain empirical questions in need of rigorous study.To identify and review survey instruments used to assess dimensions of teamwork so as to facilitate high-quality research on this topic.We conducted a systematic review of articles published before September 2012 to identify survey instruments used to measure teamwork and to assess their conceptual content, psychometric validity, and relationships to outcomes of interest. We searched the ISI Web of Knowledge database, and identified relevant articles using the search terms team, teamwork, or collaboration in combination with survey, scale, measure, or questionnaire.We found 39 surveys that measured teamwork. Surveys assessed different dimensions of teamwork. The most commonly assessed dimensions were communication, coordination, and respect. Of the 39 surveys, 10 met all of the criteria for psychometric validity, and 14 showed significant relationships to nonself-report outcomes.Evidence of psychometric validity is lacking for many teamwork survey instruments. However, several psychometrically valid instruments are available. Researchers aiming to advance research on teamwork in health care should consider using or adapting one of these instruments before creating a new one. Because instruments vary considerably in the behavioral processes and emergent states of teamwork that they capture, researchers must carefully evaluate the conceptual consistency between instrument, research question, and context.