Jeff GrimTrack – Building RC for Educational Improvement

FacilitatorJeff Grim, University of Michigan, USA


OrgAnne Douglassanizational change and quality improvement in urban child care centers – Perspectives from relational bureaucracy theory

Anne Douglass (University of Massachusetts Boston)

Country: USA

Overview: High quality child care is essential to promoting healthy development and closing the achievement and opportunity gaps for young children. Yet child care quality improvement efforts frequently fail to achieve their desired results. Relational bureaucracy and relational coordination theories suggest that relational and structural organizational approaches are far more effective than current efforts to improve child care quality. This multiple case study examined the implementation and impact of a learning collaborative model for quality improvement in urban child care settings. Study findings show how improvements in practice were facilitated by changing relationships and structures in child care center.

Context: This study examined the implementation and impact of a quality improvement collaborative that was designed to promote the adoption of trauma-informed practices in urban child care settings. The model was based on the Breakthrough Series Collaborative methodology for improvement, and included a focus on building relational capacity for organizational change. This study investigated how early educators implemented new practices as a result of participating in this initiative. The theoretical frameworks guiding this study are drawn from relational coordination and relational bureaucracy theories (Gittell, 2006; Gittell & Douglass, 2012), and the improvement science literature (Bryc, 2010; Bryc, Gomez, Grunow, & LeMahieu, 2015; Institute for Healthcare Improvement, 2003; Halle, 2013).

Study Design and Research Methods: Six child care programs serving low income families were selected by the city to participate in both the intervention and this study. The study used a structured, qualitative, multiple case study methodology (Yin, 2014) and included data collected through interviews, observations (of classroom quality and the intervention), and document review. This method allowed for an ecological framework that took into consideration the complex and interacting organizational and collaborative learning environments and relationships that fostered or hindered teacher learning and organizational change (Bronfenbrenner, 1979). Data were analyzed through a set of structured qualitative coding methods and cross-case comparison techniques (Miles, Huberman, & Saldana, 2014; Yin, 2014).

Summary of Key Findings: The intervention was found to foster organizational change through the implementation of new structures and more positive relationships in child care centers. For example, results show how the use of cross-role teams positively influenced early educators’ capacity to learn and apply new knowledge to improve their practice. By bringing together participants from across diverse roles, the intervention fostered a collaborative learning community within programs. A focus on mutual respect enabled more positive relationships within and across roles. These changes enabled the cross-role teams to plan together how to make changes in their practice and problem-solve to overcome barriers to change. In addition, teams learned how to create the infrastructure needed to support change. One of the most significant changes here was establishing regular weekly team meetings. In most of the participating programs, teachers were assigned to work directly with children all day, with no paid planning time. A key component of the implementation infrastructure was to overcome the barriers to establishing and maintaining a weekly team meeting routine that enabled organizational capacity for change and improvement.

Sana ShaikhCreating & Sustaining Culturally Responsive Classrooms: Exploring the Role of Relational Coordination in Connecticut Schools: A Mixed-Methods Study

Sana Shaikh (Brandeis University)

Country: USA

Connecticut is the wealthiest state in the United States based on individual income but that wealth is disproportionately concentrated among the top 1% (Radelat, 2015; Caplan, 2016). Connecticut also has the country’s largest achievement gap, most segregated school system based on race, and a troubling legal history when it comes to providing students of color access to an equitable education (Caplan, 2016). Empirical studies have documented the persistent inequities that plague schools, in part due to discriminatory legal, political, and social policies that have disproportionately impacted students of color and their families. These problems are compounded by the organizational structure of urban schools. Lack of communication, mistrust, and misalignment within the school negatively impacts student learning outcomes. Relational coordination, a theoretical and methodological framework, shows how “shared goals, knowledge, and mutual respect” coupled with “frequent, timely, and accurate communication” can help improve students’ learning within the classroom (Gittell, 2010). Furthermore, culturally responsive teaching can help teachers create an equitable learning environment for their students. CRT focuses on the holistic development of a child, focusing on academic, socioemotional, and behavioral growth as metrics for student success.

The proposal dissertation will use a mixed-methods design. Connecticut public school teachers identified as culturally responsive will be sampled to measure relational coordination at their schools. This will specifically be among teachers and school administrators, teachers and their colleagues, and teachers and their student’s families. In-depth interviews and classroom observations will provide a qualitative understanding to how relational coordination shapes the culturally responsive instruction of teachers within the classroom. The surveys and interviews will be aimed at teachers, individuals who have the most direct impact on student learning in the classroom. The study will sample urban Connecticut schools, schools that have often served the most vulnerable student populations.

The overall purpose of this project is to analyze the significance and impact of relational coordination in Connecticut schools and its impact on the development of culturally responsive classrooms. Critical race theory, intersectionality, and relational coordination are the three theoretical frameworks that guide this study.

This is an important study because it seeks to merge different theoretical frameworks to help identify the variables that create culturally responsive classrooms for students of color. While empirical studies have documented the merits of cultural responsiveness, minimal research has explored the organizational factors that impact its success. Students of color have historically faced deep-seated inequities and those disparities are only compounded in urban schools with weak organizational structures. This study seeks to develop the scholarship base about culturally responsive teaching by exploring how and why relational coordination impacts student learning within the classroom. Findings are expected to show that schools with high levels of relational coordination among teachers, the administration team, and student families create and sustain culturally responsive classrooms.

Cady LandaPolicy and organizational influences on ability of a public elementary school to meet special needs of children of immigrants with low income

Cady Landa (Brandeis University)

Country: USA

This is a case study that uses ecological (Bronfenbrenner, 1979) and relational bureaucracy (Gittell & Douglass, 2012) theories to examine public policy and organizational influences on the ability of a public elementary school to meet special needs of children of recent immigrants and work with their parents in that process.

Research questions are:

1. How do public policies and organizational structure influence how staff of a Massachusetts elementary school respond to special needs of children of recent immigrants and work with their parents in that process?

2. What are the patterns of parent experience in navigating education systems and interacting with school staff on behalf of their children? What are the influences that shape those experiences in particular ways?

Purposeful sampling was used to select the school from among those in Massachusetts. It is located in a city among those with the highest number of immigrant families with low income in the state, and the school itself has higher than statewide proportions of students whose first language is not English and whose families are income-eligible for free or reduced-price lunch. The study examines the focal work processes on behalf of ten selected students within the school whose parents immigrated to the U.S. as adults, have low income, and whose academic or social performance is the subject of parental or school concern. Data is drawn from (1) semi-structured in-depth interviews with all school staff serving each of the selected students, their parents, and school and district administrators and (2) district and school procedural, and federal, state and local policy documents.

The change that is the focus of this study is that which is brought about by immigration — an important topic at a time of heightened worldwide migration. How does school organizational structure interact with public policy to shape the response of the school to a population altered by immigration, and what are the implications for individuals served? The study examines role relationships between the principal and staff, and among school staff, on behalf of students, and particularly focuses on the quality of the co-productive relationship between school staff and parents who immigrated to the U.S. as adults.

Preliminary findings reveal need for school organizational structures providing increased levels of support for (1) collaboration among school staff on behalf of individual students, (2) co-production of recently immigrated parents and school staff and (3) participation of front-line staff in evolving the system to meet needs of current students and families. Also emerging is the importance of a public policy environment that provides children of immigrants with access to health care and Early Intervention; their parents with systems knowledge; and schools with adequate resources for interpreters, translation and supports for parents. It is becoming apparent that multilingual education and universal design for learning, that customizes educational services for all children (without eligibility criteria), would support school staff in meeting needs of children whose first and home language is not English. The under-resourcing of schools is another strong emerging theme.

New work time legislation in Danish public schools calls for relational coordination

Karen Albertsen & Hans-Jørgen Limborg (Team Working Life)

Country: Denmark

In 2014 the Danish government together with other parties in the parliament agreed on a large reform for the public schools. This reform required changes in the working time agreement for the teachers, among others with demands of longer presence time and less flexibility in schedule. The negotiating partners from the municipalities and from the teacher’s union didn’t manage to make an agreement. The conflict ended in lock-out of the teachers and the government intervened with a new working time legislation. In some of the municipalities, the conflict continued at the local level as disagreements between the administration in the municipality and the representatives from the teacher’s union.
This project evaluated how this new working time legislation was implemented in 6 public schools within a municipality, that have tried to guide the process though a locally written foundation for the administration. Altogether 23 focus group interviews were performed with teachers, representatives, principals, and managers from 6 schools selected out of the 19 public schools in the municipality.

Results showed that all schools had had a hard time with the implementation of the legislation, but most schools found the written foundation for administration to be helpful. The teachers in general found that the time for preparation was all too limited. Some felt torn between solidarity with the pupils, who they wanted to give qualified and prepared education and solidarity with the colleagues – demanding them not to work overtime. However, there were large differences in the implementation process among the schools, with some schools challenged by feelings of lack of justice in the organization of schedules and division of tasks, while other schools had found their own way in adjusting to the reform. What differentiated the schools were the degree to which they had managed to balance between on the one hand flexibility in working time and organization of work and on the other a strong focus on the shared goal and direction for the school. In the most well-functioning schools this balance was obtained through a close collaboration between the management and the teachers representatives, securing that the voice of the teachers were heard in the decision process.

At the school level as well as at the municipality level, there was a huge need for a shared understanding between teachers, school managers and the administration in the municipality, not only concerning shared goals and directions for the schools, but particularly in manifesting mutual respect between the different partners for the practical possibilities, priorities, choices, and solutions. The written foundation for the administration seems to represent a single step in the right direction, and the evaluation turned out to be another step bringing the partners closer together by giving voice to the schools.

Erik VestergårdEmbedding relational coordination into professional education

Erik Vestergaard (Absalon University of Applied Sciences)

Country: Denmark

The Danish public welfare services are in these years, under pressure to produce more welfare in a higher quality and/or the same for less. In addition to that, the welfare professionals, are expected to engage in close co-creation and/or co-production (in Danish; ‘samskabelse’) with the citizens (Hulgård et al., 2016, Pedersen-Ulrich, 2016). When New Public Governance as management paradigm, are put into play, in the public sector, there are challenges to consider, regarding cooperation and collaboration emphasizing capacity building (Krogstrup, 2017 (red.)) between multiple stakeholders. Additionally arise, as a result of new welfare policy-intentions, previously unknown implications for the welfare professionals way of practice, and how to educate and develop the mindset and skillset, that can support this irreversible process. This paper is focusing on how to embed Relational Coordination in education of leaders of welfare professionals at University Colleges. The cource is called ‘Management of Co-creation Processes’ and the learning objectives are to enable the participants to lead collaborative processes across professionals, citizens, volunteers and other community actors, as well as lead solution-oriented processes in and across welfare organizations.

Leaders in welfare organizations, are educated in different (co-existing) paradigms (Kuhn, 1962, Lerborg, 2013) and need to understand, and be able to act, in this new emerging welfare paradigm. At University College Zealand (UCZ), there is a strong focus, on how to create transdisciplinary learning designs, that enable leaders and employees, to engage this new social and political agenda. By developing new ways of teaching at further education (Bachelor Degree Programs) for leaders, with emphasis on bringing leaders and employees together, in engaging this challenge, UCZ are working on creating new ways to educate and distribute learning into communities of practice. The purpose is to transform these new types of relationships into high performance, though social innovation (Drucker 1985, Darsø 2011) – for the benefit of the citizens and the welfare society in general.

The education of leaders, has for many years emphasized corporative learning (Kagan and Stenslev, 2007) where the students work individually and on different and independent goals. Leaders need to be educated on how to understand, design, and transform relationships in micro, meso and macro perspective, that enable them to facilitate processes as collaborative learning (Bang og Dalsgaard, 2005) using the theory of Relational Coordination (Gittell, 2012, 2016).

The field they enter is ‘inhabited’ by different stakeholders with sometimes very different needs and agendas, that often are characterized by conflicting intentions (Gullestrup, 2016). Relational Coordination is for many students/leaders easy to understand and relate to, and provide them with a relevant ‘backdrop’ to understand how to lead co-creation based upon shared goals, shared knowledge and mutual respect. They often express relief when they are presented for this theory, that help them to understand and to communicate about the complex task they are facing. And most important, Relational Coordination helps them, to make the necessary changes in their organizations.

Course overview (themes):
• Co-creation as a management paradigm
• Co-creation as a process for social innovation
• Management and co-creation
• Methods of leadership and measurement of co-creation
• Personal leadership in co-creation processes

Track – Building RC Into Community-Based Care

Facilitator: Jens Ravnholt, Region North Jutland, Denmark

Person-centred approach to health and social care integration – Building RC in the National Health Service

Presented by Hans Hartung (NHS Ayrshire & Arran, Scotland)

Co-Authored by Erica Reid, Alison Anderson & Carol Nixon (NHS Ayrshire & Arran, Scotland)

Country: Scotland

Background – People with long-term conditions often experience fragmented and uncoordinated health and social care. This can lead to problems including repetition of assessments, poor transmission of information and delays in care.
Our project tried to improve quality of care and patient experience by gaining insights from patients and clinical teams using an Integration and Relational-Coordination Survey and subsequently acting on the results to improve care integration.

Method  – Our project encompassed three elements:
1. Asking patients about their experience of integrated care using Sara Singer’s (Harvard School of Public Health) Integration Survey adapted for Scottish context (1).
2. Asking staff and patients about the effectiveness of relationships and communication between and across teams delivering respiratory care using Jody Hoffer Gittell’s (Brandeis University, Boston) Relational Co-ordination Survey (2).
3. Using quality improvement methods to make collaborative improvements to the health and care pathways (3).

We tested the approach with a cohort of people living with Chronic Obstructive Pulmonary Disease (COPD) from four General Practices in Ayrshire & Arran, Scotland along with health and social care staff involved in their respiratory care (GPs, Practice Nurses, District Nurses, Community Pharmacists, Care at Home staff and Respiratory Specialists).

Large workshop events and small group meetings were held with participants to allow feedback of results, reflection, discussion and identification of areas for carrying out improvement initiatives.
A patient focus group in the form of a storytelling workshop was also held.

Results 501 out of 1001 patients with COPD completed the Integration Survey (50% response rate). The Relational Coordination Survey was completed by 102 out of 151 health care professionals (68% response rate). The shared learning from both surveys resulted in 8 improvement initiatives.

Conclusions – The surveys provided a basis and new lens for reflection and discussion from different perspectives, that kick-started an action-focused drive towards achieving quality improvements across the COPD health and social care continuum.

The project provided valuable insight, from service users’ perspectives of the complexity of the health and care systems that they are attempting to navigate. This helped focus discussions on how we can work with service users to make our systems more integrated and person-centred.

We were successful in bringing service users and staff together in a positive, inspiring and energizing way that has enabled communication and relationships to have significantly increased prominence in improvement work.

Our work has broken new ground in this respect, and provides a fresh dimension and excellent platform on which to progress improvement initiatives and build a quality improvement and learning culture. There is no doubt that the relational coordination element, in particular, has provoked and enabled discussions within and between teams that is unlikely to have taken place otherwise. We believe that the relationship and communication aspects that relational coordination encompasses are vital considerations in any improvement work, and we are considering how best to integrate this in on going improvement initiatives.

1. Singer SJ, Burgers J, Friedberg M, et al. Defining and Measuring Integrated Patient Care: Promoting the Next Frontier in Health Care Delivery. Med Care Res Rev 2010; 68(1): 112-127.
3. Langley GJ et al. The Improvement Guide 2009.

Moving from person-centered to relationship-centered care in the community – Testing innovative interventions

Presented by Hebatallah Naim Ali (Brandeis University)

Co-Authored by Frannie Raede, Joanne Beswick, Laura Lorenz, Marji Erikson WarfieldAndy Molinsky & Christine Bishop (Brandeis University)

Country: USA

Introduction: The purpose of residential care has evolved to become increasingly focused on providing residents with a “life in the community.” It is a relational vision of care that goes beyond the staff/resident dyad to encompass a broader system of resident family and community connections and relationships. Yet the human resource and other institutional supports have not caught up with this relational vision of care. At the same time, there is a cultural and racial divergence in the residential care sector due to growing reliance on U.S. born and immigrant workers of color to serve residents who are largely low income (Medicaid eligible) and white in residential facilities located in communities that are largely middle class and white.

Research Questions: Using an interventional research design in two group homes serving people with chronic moderate to severe brain injury, this study asks: 1) What are the challenges for community based care in the context of cultural/racial divergence between staff, residents, residents’ families and the communities in which they are embedded? 2) Can a staff-led intervention informed by the relational model of organizational change address these challenges? 3) What issues related to sustainability are identified?
Research Context and Methods: The research context is residential care for persons following moderate to severe acquired traumatic brain injury for greater than one year (from traumatic brain injury, stroke, brain tumor and anoxic encephalopathy). Based on theoretical sampling, we selected two sites in the Boston suburbs of eastern and central Massachusetts, one that is a traditional larger residence and the other a small residence using a waiver model that is on the rise. Both have staff who are primarily persons of color and recent immigrants, serving residents and families who are white and from lower to middle income.
To answer our research questions, we used an interventional research design informed by the relational model of organizational change, with six stages of change. Both quantitative and qualitative data were gathered.

Findings: Data from this project are currently being collected and analyzed. The proposed presentation will present (1) descriptive quantitative data from the baseline assessment of relational coordination (RC) at both sites; (2) narratives about the recruitment, formation, and operation of the change teams at each site; (3) descriptions and pictures of the community-based and family-based interventions implemented at both sites; (4) data comparing the baseline and follow-up data gathered on RC at each site; and (5) themes from the follow-up qualitative interviews conducted.

Discussion: The findings will be discussed to highlight (1) the potential for RC interventions to promote higher quality care at residential facilities for persons following moderate to severe acquired traumatic brain injury and sustain a quality workforce; (2) lessons regarding HR practices that can support sustainable RC approaches to care provision; and (3) policy strategies for facilitating RC approaches on a larger scale.

Takashi NaruseThe association between nurses’ coordination with physicians and clients’ ability to die at home

Presented by Takashi Naruse (The University of Tokyo)

Co-Authored by Natsuki Yamamoto, Takashi Sugimoto, Mahiro Fujisaki-Sakai & Satoko Nagata (The University of Tokyo)

Country: Japan

Over 60% of Japanese people hope to die at home; hence, assisting clients in achieving this outcome is an important responsibility of home care providers. This study investigated the effects of nurses’ relational coordination with physicians on clients’ place of death in home visiting nursing (HVN) agencies.

Secondary analysis of a public survey conducted in 2015 by local governments in Kurume city, Fukuoka prefecture, Western Japan. Manager nurses from 17 HVN agencies provided data about themselves and their relational coordination with community physicians and 85 deceased clients.

Among 85 deceased clients, 52 (61.2%) had died at home. Four regression models showed significant positive effects of HVN nurse managers’ relational coordination on clients’ home death (the odds ratios (95% CI) were 2.488 (1.442-4.293), 2.111 (1.014-4.396), 2.562 (1.409-4.658) and 2.275 (1.079-4.796) in models 1-4, respectively.

Measuring relational coordination among HVN nursing managers and physicians indicated readiness for home death among HVN clients in an agency or community.This report has been already accepted on International journal of palliative nursing (23, 3, 2017).

An investigation of relational coordination within interprofessional somatic rehabilitation teams and the patients’ perspectives on continuity in Western Norway – A cross sectional study

Presented by Merethe Hustoft and Eva Biringer (Centre for Habilitation and Rehabilitation/University of Bergen, Helse Fonna Local Health Authority, Norway)

Co-Authored by Sturla Gjesdal, Jorg Amus & Øystein Hetlevik, Centre for Habilitation and Rehabilitation in Western Norway, Helse Bergen Local Health Authority, Bergen, Norway, Institute of Global Health and Primary Health Care, University of Bergen, Bergen, Norway

Country: Norway

Background: Core skills of interprofessional rehabilitation teams are: communication, relational ties, cooperation, coordination and continuity (Momsen, Rasmussen, Nielsen, Iversen, & Lund, 2012). Research shows that smaller teams with greater occupational diversity are associated with higher overall effectiveness (Deneckere et al., 2013; Xyrichis & Lowton, 2008). Further, an interprofessional team requires the participation of multiple participants in care coordination (Zwarenstein, Goldman, & Reeves, 2009). High degree of Relational Coordination (RC) within interprofessional teams has shown a positive influence on the quality- and coordination of care (Gittell, Godfrey, & Thistlethwaite, 2013). The aim of this study is to investigate RC in interprofessional rehabilitation teams in Western Norway and to investigate associations between RC and patients’ perspectives on continuity.

Setting: Western Regional Health Authority serves approximately 1 million inhabitants. There are seven specialised somatic rehabilitation institutions situated in urban and rural areas of this region. These institutions are contracted by the Western Regional health Authority to deliver specialised somatic rehabilitation services. The institutions are organised as having one to four interprofessional rehabilitation teams. Each team has five to 17 team members. There are five main functional groups included in each team; physicians, nurses, physiotherapists, occupational therapists and others. All patients referred to one of these seven specialised somatic rehabilitation institutions 1st January 2015 to 30th June were included in this study.

Methods: This is a cross-sectional study using data from 15 interprofessional rehabilitation teams in seven rehabilitation institutions in Western Norway. RC was measured by the Relational Coordination Survey (RCS), distributed to 166 individual team members (N=94, 56% response rate). If respondents belonged to more than one team they would answer the RCS x times teams they belonged to, giving 231 potential responses (N=124, 54% response rate). Patients perspectives on continuity was measured by Nijmegen Continuity Questionnaire (NCQ), distributed to 984 patients with a stay in one of the seven rehabilitation institutions (N=705, 72% response rate). All patients were linked to which team of health care professionals they were treated by during their stay at the rehabilitation institution. Linear and multiple regression models will be employed to analyse associations between team members’ RCS scores and patient-reported NCQ continuity scores. RCS Communication- and Relationship sub-scales and –total scale will be entered as predictor variables and the NCQ sub-scales as dependent variables. Level of patient-experienced coordination as measured by the NCQ sub-scales will be investigated as function of team properties, i.e. team members’ total years of experience, size of team, age of team members and professional /functional groups included in the team. The analyses will be adjusted for patients’ age, education level, diagnosis/functional level or municipal living area (urban/rural), which may confound the association between relational coordination in interprofessional teams and patients’ experiences of care coordination.

Expected findings: We expect to find associations between communication and relationship skills in specialized somatic interprofessional rehabilitation teams and patients’ experiences of care coordination.

Patient centered care and relational co-production in the Netherlands Jane Murray Cramm

Presented by Jane Murray Cramm (Erasmus University Rotterdam, Department of Health Policy & Management (iBMG))

Co-Authored by Leontine van der Meer, Liana Hakobyan, Anna Petra Nieboer, Harry Finkenflügel (Erasmus University Rotterdam, Department of Health Policy & Management (iBMG))

Country: Netherlands

People’s ability to remain independent and care for themselves as best and as long as possible is becoming increasingly important, not least because it can relieve the burden on healthcare systems resulting from increasing demands for care and support. Currently, most preventive community and primary care interventions are aimed at physical health only. However, effective population health management and prevention efforts in the community must extend beyond the self-management of chronic conditions to include the broader management of overall well-being. Investing in relational co-production seems beneficial as Dutch studies clearly show, not just for patients, but for formal and informal caregivers as well. Furthermore, the application of social production function theory allows us to pin-point how community care effort help support people’s production of well-being. With such efforts, we can expand our theoretical understanding of community care and people’s well-being in various settings

Track – Building RC, Respect and Trust

Facilitator: Tahereh Barati, Vrije Universiteit Brussel & Taos Institute, Canada

Peju Solarin
Fostering cooperation through respect – Lessons from mediation

Adepeju O. Solarin (Program on Negotiation, Harvard Law School)

Country: USA

Respect as an idea or concept is under-researched and undervalued especially in conflict resolution or problem-solving contexts. For example, there is an underlying and unspoken rule that mediators must be respectful and provide respect to all stakeholders as they conduct their problem-solving efforts. However, little information exists on how this expectation of respect can affect a mediator’s effectiveness during resolution efforts, particularly as their manner of communicating and relating can have significant influence on cooperative behaviour amongst stakeholders. This presentation seeks to address the deficiency in research by focusing on respect as a critical tool for creating and sustaining cooperation through specific change in communication and behavioural interactions amongst stakeholders.

The audience will, first, be introduced to an interdisciplinary research framework (restorative justice and international relations) that discusses respect and provides a rationale for how it (respect) served as a foundational pathway contributing to the eventual peace agreements signed by the opposing stakeholders. Based on a multi-year study which examined contemporary cases of international mediation events—two of which were the Oslo-Israeli/Palestinian and 2003 Accra-Liberian peace processes—a tri-model respect typology that positively influences stakeholders (in conflict) is developed. The three types are respect-as-modeling-behaviour (RasMB); respect-as-balance (RasB); and respect-as-shared-experience (RasSE). Second, the meticulous data sets for the two cases will also demonstrate the undervalued link between respect and cooperation. Data sets included situational ethnography which reconstructed the Oslo case producing a 20, 297-word transcript of the meetings in Oslo; expert interviews with the Accra mediation team; while the method of qualitative content analysis was administered to the sets.

A critical finding of this project uncovers a functional delineation between respect and trust. Furthermore, it uncovers that respect precedes trust. Additional findings suggest that the explicit use and display of respect by mediators not only fostered a cooperative attitude amongst the stakeholders in conflict, but in some cases proved more critical than the need for trust.

The novelty of this respect research is that it increases the likelihood of adversaries coming to, and remaining at the table. Through the earlier-mentioned tri-model typology and the respect-trust delineation, paradigmatic shifts are warranted, which necessitates practice implications in the contexts of conflict resolution and problem-solving. The presentation will highlight a practice implication demonstrating how and why respect is central to relational coordination approaches.

Relational coordination and social capital at the workplace – How are the measures associated?

Karen Albertsen, Inger-Marie Wiegman & Hans Jørgen Limborg (Team Working Life)

Country: Denmark

The approach of workplace social capital has received a considerable attention in Denmark within the latest decades, and the concept of relational coordination, and lately also professional capital, has further added to this attention on the quality of social relations at the worksite. Workplace social capital has been defined as ‘…the social relations evolved from the solution of the core task of the workplace. This includes both the relationships between the employees and managers and among employees and managers respectively.’ (Hasle et al, 2010). The concept has in a Danish context often been operationalized into the dimensions of trust, justice and ability of collaboration, and many workplaces has measured the level of social capital annually. Obviously social capital and relational coordination is closely connected concepts, but how closely are the measurements of the concepts associated? To what extent is there agreement between the measurements of the one and the other? The purpose of this study was to qualify the discussion of the practical application of measurements of social capital and relational coordination in the creation of change and development at the worksites. Specifically, we examined the extent to which employees’ responses to questions about relational coordination was associated with their answers to the questions of social capital, and to what extent the two concepts were associated with some key factors related to the psychosocial work environment, namely job involvement, perceived quality of work and psychological well-being. Finally, we examined whether the results could support a mediating effect of social capital between relational coordination and the three outcomes. That is, whether relational coordination contributes to social capital which in turn contributes to job-involvement, perceived quality, and psychological well-being. The study was based on cross sectional survey data reported by care workers as part of the project Relational Coordination in everyday rehabilitation. This project was conducted between 2012 and 2013 in five Danish municipalities, all in different phases in a process implementing everyday rehabilitation in the home-care. In summary, the results showed a moderate agreement between measurements of social capital and relational coordination, and between each of the two factors and the three outcomes, respectively. Further, they supported the assumption that the relationship between relational coordination on the one hand and psychological well-being, involvement and quality of work were mediated by social capital. In relation to practical experience the results make sense. The social capital issues of trust, justice and collaboration seem to function as key markers of the quality of working relationships. They can give overall corrections of the direction of development, but they are not concrete action oriented. The answers to questions about relational coordination characterize the quality of specific relationships and the nature of the communication that carries them. They may guide the development of the relationships or point to elements of communication that can be expected to have the greatest impact on improving cooperation.

The people make the place – A multi-level study of the impact of relational coordination on proactive behaviors

Presented by: Patrick Flood (Dublin City University)

Co-Authored by: Jennifer Farrell (Dublin City University) Gerard Hodgkinson (Alliance Manchester Business School, UK ) & Karoline Strauss (Essec Business School, France)

Country: Ireland

Proactive behaviour is about ‘making things happen’. As proactive behaviour often results in change that affects others, this paper argues that making things happen is a social process involving interaction with a range of potential others in the workplace rather than a single individual act played out in isolation. While research exists to suggest that job context influences proactive behavior, much less is known about the role of social context, and in particular, the role of positive relationships in fostering proactivity. Accordingly, this paper develops and tests a cross-level model, in which the proactive work behavior of individual nurses is modelled as a function of the quality of the individual subjective relational experiences they have at work. At the individual level, role breadth self-efficacy is proposed as a mediating mechanism between subjective relational experiences and individual level proactive behaviour. At the team level, this paper examines how shared perceptions of relational coordination within teams can promote and enable individuals within those teams to engage in self-initiated change oriented proactive behaviour. The paper also proposes that a psychologically safe work climate is an important linking mechanism between relational coordination climate and individual proactivity.

The Collaborative Intelligence Laboratory – How to build a bigger we 

Anders Risling (Anders Risling AB)

Country: Sweden

The focus of the session is an inquiry around intervention principles for development of collaboration between interdependent groups. We have designed the Collaborative Intelligence Laboratory – CIL. Each CIL has its unique structure depending on the organization and practitioners involved. Still, CIL is always building on the principles of collaborative intelligence measurement, action learning, reflective practice, zone of proximal development and scaffolding. We will present these principles and one case in detail.

This CIL was hosted by 12 senior clinic leaders in a Swedish health care region employing 13,000 healthcare professionals. The region had been struggling with finding ways of cooperating across structural borders. Multiple initiatives had been taken to make the system function as one body, such as implementation of lean principles and adjustment of organizational structures. Despite these initiatives, the organization found itself under struggling with growing pressures to be more efficient and create a better value for the patients and also to prepare to meet the demographic, technological, political and financial challenges. Therefore, in the beginning of 2016, the 12 12 senior clinic leaders took the strategic decision, sponsored by the executive director of the region, to work collectively with the entire system to enhance and encourage self-organized cooperation throughout the system and especially amongst clinics. Collaborative Intelligence Laboratory was one important intervention, or step on the path to achieve their goal.

Affective processes play a significant role in the development and maintenance of intergroup cooperation. When such emotions become linked to psychological, social and organizational dynamics complexity increases and there are real and ample ground for intergroup conflict impediment of effective cooperation amongst interdependent professionals and decision makers.
Today, we know quite a lot about intergroup cooperation, but we know less about which specific interventions that bring on and boost collaboration between groups. It is one thing to bring the problems connected with lack of cooperation to attention, and quite another to accentuate the positive power of trust and difference. How we can tap that power? Is it possible to actively boost positive social affections, engaged kinship and inspired engagement with members of other groups?

We will describe how leaders and professionals in an action learning and large group setting together with 60 other stakeholders grounded developed positive social affections and collaborative intelligence using both diagnostic and dialogue based interventions. We will describe an intervention theory which take into consideration both stakeholders’ collaborative intelligence and the systems level of complexity. As practitioners, we have found that authentic collaboration very often is the result of small, separate events as these are linked and amplified. During CIL, participants involve themselves in a vital, authentic process where they examine these events and build the mindset and practical capacity supporting them in bringing on these discriminable processes in order to enable cooperation across the structural borders of the system.

Track – Strengthening RC, Coproduction and Trust in Virtual Networks

Facilitators: Ragnhild Kvaushagen, BI Norwegian Business School, Norway

Trust through diverse interaction for community based mental health services

Angela Aristidou (Warwick Business School, CASBS Institute (Stanford))

Country: UK

Trust among people-in-roles who enjoy official (cross)organizational links with one another is well understood. We know, for example, that trust between a current customer and a worker is a significant element (e.g. Gutek, 1999), and is built over time and through repeated interaction (Gutek et al., 2000). When we consider diverse interaction (i.e. amongst multiple actors with or without official links), then what is the role of trust and how does it contribute to maintaining service provision for a patient? I examined this question through my eighteen-month qualitative study of UK mental health services. Through interviews, documents and observations, my findings illustrate how trust is generated over time among people in position-practices (Giddens, 1984; Stones, 2005) who may not necessarily have (cross)organizational links. In a surprising twist, my findings also extend our understanding of the temporal dimension of trust. I illustrate how trust generated in the past between a past customer and a worker may influence the building of trust between the current patient and the (same) worker. This shows that a broader range of influences such as the trust built from others’ repeated interaction can provide confidence and comfort to an individuals’ understanding of a role-based relationship before it even occurs. By adopting a position-practice relations perspective (Stones, 2005), the insight that interaction that took place in the past may additionally bring together agents linked in practice through space and time, opens up new and exciting avenues for future research.

VeteraLynn A. Garvinns’ patient engagement and user satisfaction through relational coproduction with providers through use of VA’s My HealthEVet patient portal

Presented by Lynn Garvin, BUSPH

Co-Authored by Kim Nazi, Marianne Pugatch & Eric Pruyne (BUSPH, VA, Brandeis University)

Country: Brandeis

Background: Accelerating patient engagement through improved digital experience is a broad-reaching goal of the U.S. healthcare system and a specific aim of the Veterans Affairs (VA) Transformation Initiatives. VA’s My HealtheVet (MHV) patient portal offers veterans a suite of online health information tools to support their self-management and care coordination with clinicians, that is, their “relational coproduction” of health and healthcare as specified in Relational Coordination (RC) theory (JH Gittell 2012, 2016). Research at VA and other U.S. healthcare systems has shown that technology like MHV can improve patients’ satisfaction with their digital experience and patient engagement, promoting health and quality of care. But this is the first study to examine veterans’ own recommendations for improving online tools and services that support their health and healthcare coproduction, resulting in an increase in their user satisfaction and digital patient engagement.

Objectives: This study has three aims: (1) to define ‘relational coproduction’ in the context of patient use of health IT; (2) to examine veterans’ recommendations for improving My HealtheVet tools and services to support their relational coproduction with VA healthcare teams; and (3) to determine if and how such improvements might increase veterans’ user satisfaction and digital patient engagement.

A 2013-2014 survey of U.S. veterans, made possible by the VHA Veterans and Consumers Health Informatics Office (V/CHIO), was conducted online via MHV. It produced an anonymous, random sample of 23,000 write-in responses to the question: “What is the main improvement that you would suggest for My HealtheVet?” We use ATLAS.ti qualitative research software to identify and analyze independent variables (e.g. RC’s dimension of “mutual respect”) that emerge from veterans’ responses. We next relate these to the dependent variables (digital patient engagement and user satisfaction), and examine covariates (respondent sociodemographics). Analyses examine MHV’s two salient features: (A) Blue Button which allows veterans to download their personal health records to share with the healthcare team and others they trust; and (B) Secure Messaging which enables veterans to engage in online communication with their healthcare team. Additionally, we analyze veterans’ comments as they relate to (C) MHV in general and to (D) healthcare management by the Veterans Health Administration (VHA).
Anticipated Results

The study will define relational coproduction in a digital setting and apply RC theory to data of veteran comments to support VA and My HealtheVet’s current quality improvement goals. Based on RC dimensions, it will suggest which improvements veterans propose for Secure Messaging or Blue Button/Other MHV Tools for managing their care with their healthcare teams, and at what frequency. It will explore those improvements that veterans propose for My HealtheVet in general or for the VHA for managing their care, and at what frequency. Finally, the study will examine the sociodemographic covariates to suggest which improvements, if any, vary depending on respondent characteristics, and at what frequency. When possible, findings will be illustrated with charts and graphics.

Creating change through trust based virtual relationships to deliver high quality care and drive growth

Niña Ellison & Kathleen Dailey (MinuteClinic)

Country: USA

Summary of project
The Education team at MinuteClinic has developed a national series of regularly scheduled virtual educational connections to advance clinical knowledge while enhancing the depth of relationships across our practice. Our model of practice is a unique sole-provider model. Actualizing transformational growth is a critical component of the horizontal scaffolding being built by this education team. There is also consideration of the challenge to extend relational coordination theory beyond role relationships and also include personal relationships and the exploration of the interplay between them (Gittell, 2011).

The context
MinuteClinic is the walk in clinic within the 1000+ CVS pharmacy stores in the USA. The Education team at MinuteClinic was formed in 2016 with a total of 26 Field Educators, 3 Senior Education Managers and 1 Director. This group was developed to advance the clinical practice of approximately 3,000 nurse practitioners and physician assistants within the national retail healthcare group practice setting. The context of this project is primarily completed within a virtual environment. The leadership of MinuteClinic supports innovative campaigns for change, encouraging the field leadership team to engage in new ways of thinking and in new ways of doing things. Despite this, empowering large groups of providers to embrace the complexity of a change is often challenging. Recognizing the elements of trust is vital to the success of our practice.

The methodology
The theoretical underpinnings of relational coordination support the methodology for this work that includes understanding and developing the infrastructure needed to support a variety of sustainable, virtual-focused connection points to build a flexible and responsive clinical communication strategy across the practice. Change is measured through engagement and participation outcomes as well as impact to company quality and safety initiatives. The initial relationship building for this work started with the education team itself. Weekly virtual webinars with cameras in use were initiated and for the first 3 months in depth introductions by team members were included to build mutual respect and trust. Initial work also included defining our role as a newly formed team and connecting with all key stakeholders to confirm shared goals and both process and expectations for timely communication. Current systems were reviewed to determine how best to support the advancement of a platform of regular connections. Identification of the appropriate times for connecting with clinicians was studied with training of the education team in best practices for advancing the impact of virtual leadership.

The findings from this work
Through the use of a wedge and spread framework a small cohort of practice members were invited to join one of fifteen calls offered each week to review a case study. At eight weeks, outcomes of these inter-professional calls were studied. Over a 6 month period of time other focus connection calls were added as alternatives to learning and growth. Tracking of these connections and their content demonstrated the presence of accuracy, frequency, timeliness, and solution oriented connections. Clinical initiatives, safety and engagement have also been measured. Understanding the development of trust to further support “best practice” virtual opportunities remains a high priority in the progression of this work.

Carmeli, A., & Gittell, J. H. (2009). High-quality relationships, psychological safety, and learning from failures in work organizations. Journal of Organizational Behavior, 30(6), 709-729.

Dailey, K. (2015). Virtual peer coaching among advanced practice nurses. (Doctoral dissertation). Nova Southeastern University.

Gittell, J. H. (2015), How Interdependent Parties Build Relational Coordination to Achieve Their Desired Outcomes. Negotiation Journal, 31: 387–391. doi:10.1111/nejo.12114

Gittell, J. H. (2011). New Directions for Relational Coordination Theory. In J. H. Gittell. Oxford University Press. doi:10.1093/oxfordhb/9780199734610.013.0030

Gilson, L.L., Maynard, M.T., NC Jones Young, Vartiainen M.,& Hakonen, M. (2015). Virtual teams research: 10 years, 10 themes, and 10 opportunities. Journal of Management 41 (5), 1313-1337

Jannie Kristine Bang ChristensenBuilding and maintaining trust in a telemedicine network

Jannie Kristine Bang Christensen (Center of Organization, Management, and Administration, Aalborg University)

Country: Denmark

Collaboration among actors from different professions and organizations represents a significant challenge for most Western healthcare systems which often result in fragmentation of care and coordination problems (Gittell, 2009). Examining the research literature on inter-organizational collaboration closer, trust is articulated as fundamental for collaboration (Lane & Bachmann, 1998). Correspondingly, building and maintaining interpersonal and inter-organizational trust may be important to improve inter-organizational collaboration and thus address fragmentation and coordination problems within healthcare systems. However, the connection between interpersonal trust and inter-organizational trust seem blurry; is inter-organizational trust transferred to the interpersonal level and vice versa? Based on this the following research question is explored: How is trust built and maintained in an inter-organizational telemedicine network?

The study is designed as a longitudinal qualitative case study. A Danish telemedicine network consisting of 11 municipalities, 4 hospitals, and 225 general practitioners was followed for three years. The purpose of the network was to develop and implement a novel telemedicine service based on remote home monitoring of patients with chronic obstructive pulmonary disease (COPD). In this paper the focus is on how trust was built and maintained in the network. An organizational ethnographic inspired approach was used to generate data. 225 hours of observation and 48 interviews were conducted.

Using temporal bracketing two main phases are identified: 1) “Development” where a telemedicine concept was developed in the network and 2) “Routinization” where the telemedicine concept was implemented and taken in to use in the municipalities, hospitals, and the general practice clinics. In the first phase the main boundary spanners where (project)managers and administrative staff (representing a strategic/administrative level) whereas the boundary spanners in the second phase consisted of frontline staff, i.e. physicians, nurses, and doctors (representing an operational level).
Results:  The results reveal the multiplicity of trust in the telemedicine network. Trust in the network arises out of different kinds of trust, emerges from various sources, and changes over time and across hierarchical levels in the network. Trust is not transferred from one level in the network to the next or from one phase to another. Thus, strategic-level trust is not transferred or translated into operational-level trust but must be rebuilt at each level and phase. This indicates that trust in the telemedicine network was conditional and tied to the individual level, although the network is embedded in a highly institutionalized field with a tradition of inter-organizational collaboration, collective health agreements, and previously shared projects and boundary-spanning activities. Correspondingly, interpersonal trust among the boundary spanners appeared to be fundamental for developing and expanding inter-organizational collaboration in the network. Another insight about trust concerns the ambiguity of trust in the telemedicine network, where trust and distrust coexisted. Consequently, the trust dynamics in the network were highly complex and multifaceted.

An RC-view on the micro foundations of collaboration

Daniel Massie (BI Norwegian Business School)

Country: Norway

This abstract describes an ongoing research project into the intricacies of temporal strategic partnering in the Norwegian construction industry. It is a case study focusing on the relationship development between a large contractor, its client and sub-contractors. They claim that successfully realizing this billion-dollar construction and city development project depends on a paradigm shift in how they collaborate. The paper responds to the call for further research into the social and relational underpinnings of strategic partnerships in the construction industry (Bygballe, Swärd, & Vaagaasar, 2016) and aims to disentangle the micro foundations for collaboration.

In line with RC-theory, researchers have found that coordination, communication and the relationship dimensions are predictors of project success in the construction industry (Doloi, 2009). As such, the context is especially suitable for the above research question as well as the RC-tools and approach. Furthermore, a longitudinal qualitative study in this context allows for uncovering these micro foundations. From interviews, I have gathered that there is an understanding of the importance of relationships and a will to collaborate, but that actors find collaboration challenging due to its intricate nature. Although collaboration is seemingly complex and difficult, it depends on basic behavioral and interactional patterns. I hypothesize that excavating these micro foundations underpinning collaboration will not only benefit the literature on collaboration in the construction industry, but also open up a research stream on the micro foundations of RC (e.g. which behavioral patterns and beliefs underpin the seven dimensions of RC and how are they influenced?). I anticipate this to be beneficial both for researchers to understand the complexities of collaboration, as well as for practioners to better understand which behaviors should be encouraged in order to facilitate collaboration.

Track – Building RC for Healthy Communities

Facilitator:  Birgitte Torring, University College Northern Denmark


Be aware – what seems easy, can be very challenging – An ongoing history about relational coordination as a tool to increase employment in a Danish municipality

Søren Bjerregaard Kjaer & Eva Thoft (Team Working Life)

Country: Denmark

Context: Danish municipalities are obliged to help the citizens outside the labor market to get a job and to help companies to find employees. There has been a change in legislation through the recent years, demanding municipalities to focus on people who not only lack a job, but also have other challenges as drug abuse, alcoholism, psychosocial or psychical problems – for themselves or in their family. In the effort to increase employment for all citizens outside the labor market, the municipalities are supposed to do holistic efforts supporting the citizen. These changes pose huge demands on collaboration across silos within the municipality, between different teams with different legal framework, different professionals, and separate budgets.
The project: A municipality wanted to increase the collaboration and measure the relational coordination across two teams in the job-center, one team in the social center and two teams in the family-center. These teams were supposed to coordinate their efforts with the common purpose of helping the citizen closer to getting a job. All in the municipality – from directors and politicians to team leaders and caseworkers thought it was the right way to go – It has, however, been extremely difficult to do I practice. They introduced a new kind of cross-professional meeting structure with coordination meetings including participation of the citizen and representatives from all relevant centers. We have collected baseline and follow-up measures of RC and supported the process with seminars focusing on relational coordination between both care workers in the teams and team leaders. Participants were directors, bosses, team leaders and caseworkers from all relevant teams.
At the seminars, we focused on creating knowledge about each other – e.g. what is the contribution from each team to the common task. We also practiced all caseworkers investigating the relations to colleges in other teams. Qualitative results showed that the caseworkers are confident and satisfied with the meeting structure. They make better and quicker decisions, they say. Also, the citizens seem more satisfied with the case management. Still there can be cases creating doubt or disagreement, and the team leaders have a challenge to improve professional cooperation and relational coordination to support the caseworkers. Results: RC among the four centers were measured before the project started. It showed extremely low levels of RC between all groups.
From these results, it became obvious for the top management that they had a huge task in front of them to create shared understanding and supporting structures around the work. A measurement in January 2017 shows overall improvements – most in mutual respect, accurate communication, shared goals and shared knowledge. But still the relational coordination is not strong. Further improvement in relational coordination is still in focus. What seemed obvious for all stakeholders, was not that easy to implement. And this is maybe the most important point. It is hard work and takes time to create the qualifications needed to work with colleges from other teams.

Partnerships in employment

Cady Landa, Julie Christensen & Olivia Raynor (University of Massachusetts Boston, University of Iowa, University of California Los Angeles)

Country: USA

Partnerships in Employment (PIE) is a state-level systems change project funded by the U.S. Department of Health and Human Services to develop and strengthen services to support the transition of youth and young adults with intellectual and developmental disabilities (IDD) from high school to postsecondary education and competitive integrated employment (CIE). Traditionally, students with IDD have been educated in separate classes, exited high school without meaningful credentials, and placed into segregated sheltered workshops where they are paid subminimum wages.

PIE states were competitively grant-funded to establish broad consortia of public agencies and stakeholders to work collaboratively to identify system strengths and weaknesses and engage in building state and local interagency and cross-stakeholder networks committed to improving transition systems and postsecondary outcomes. These consortia were required to include, at least, the state agency responsible for adult services to individuals with IDD, the state’s education and vocational rehabilitation agencies, developmental disabilities council, University Center for Excellence in Developmental Disabilities, families of and individuals with IDD, and other key stakeholders.

Presenters include Landa, who served on the team providing T.A. to participating states, Christensen, P.I. of New York’s project, and Raynor, P.I. of California’s project.

California and New York faced similar challenges to systems change as two large states with high population, culturally diverse regions, and sub-state political jurisdictions active in shaping and implementing policy. Their approaches to developing partnerships to shape state policy and practice differed. Each approach was influenced by the agendas of those participating.

California successfully engendered the commitment of state-level agencies. Its process was highly intentional about relationship-building among participating individuals across agencies and stakeholders and sought to foster interpersonal trust and understanding of others’ agencies and perspectives.

In New York, each state agency experienced pressure to achieve individual outcomes and tended to be fearful of sharing information, particularly when it exposed weakness. Important to forward movement in NY was establishing local-level collaborative bodies among the agencies involved in demonstration projects transitioning youth with IDD from high school to CIE. Key learnings from these local collaboratives were used to inform state policy development.

T.A. for systems change was guided by a higher performing states (HPS) framework that was the product of case study of states with superior employment outcomes for individuals with IDD. This framework identified characteristics of public systems in states with the highest emerging employment outcomes for this group. Qualitative study of the experience of PIE states enabled elaboration of the HPS framework and development of a systems change toolkit for transition age youth and young adults with IDD.

Relational bureaucracy theory, that shows how organizational structures can support relational leadership, coordination among staff, and co-production between staff and client, has promise for modeling relationships that are necessary to engage the various agencies and stakeholders that must work together to provide individualized services that support the hopes and dreams of those served. Participants also found the idea of backbone organization, identified by Collective Impact theory, to be relevant to complex multi-agency, multi-stakeholder systems change efforts.

Towards relational coordination 2.0 – A case study from Danish municipalities

Carsten Hornstrup (Joint Action)

Country: Denmark

Research and Development projects in Danish Public Sector Organizations have inspired a revised version of Relational Coordination (RC). The findings are based on data and practice experiences from projects in more than 10 Municipalities within areas such as: specialized adults service (handicap, psychiatry, abuse), family units, youth and kids and unemployment. We conclude that we need to revise or add to the existing RC analysis and concept – we call it: “Relational Coordination 2.0 – from coordination to capacity”.

Level of complexity and fluctuations in place and time
The first change reflects the context of the 10 Municipalities. It is often so that more than 20 different professional groups are involved at different times with different intensity and with different groups. This results in changing working relationships over time with some but not all the other groups at the same time. With a more complex context, more complex work process and relational dynamics changing from case to case, we find that the ability to create strong relationships when and where needed is a key quality. This means that we cannot identify on a general level the units of people involved in dealing with the case, this is different from the general research in RC (e.g. airlines, surgery).

Further, working towards a common goal or purpose differs. Having to deal with complex family challenges you work from different legislative mindsets. This creates a context of competing purposes, where each unit must comply with the law of their respective profession. This both requires that leadership becomes more involved in addressing these conflicts of priority, and it requires a capacity to work from within competing agendas. Both qualitative and survey data indicates, that strong RC rests on strong Relational Leadership.

Also, a change in the RC dimensions is a natural reflection of these different contexts. When we change the context from planned flight departure and planned surgery, to complex social contexts (or similar contexts), we find the survey dimensions need to be adjusted accordingly.

These findings have led us to propose the concept of Relational Capacity as being central to building stronger RC in complex and changing networks in public sector organizations dealing with systemic challenges.
Working with Relational Capacity differs from RC in three ways.
1. First, we use a different definition from: “Communicating and relating for the purpose of task integration.” (Gittell 2016) to: The ability to create productive relationships when and where needed.
2. Second, we propose to adjust and change the 7 RC dimensions, including new dimensions: Innovation, Information sharing, Mutual knowing (Storch & Hornstrup 2017). This we do to reflect the nature of the contexts we work in.
3. Third we propose to include Transformative Leadership (Hornstrup 2015) as part of the model. We do so because leadership support in all cases have been a key indicator of high RC.

HCurt Lindbergeightening staff engagement in primary care: A comprehensive strategy informed by relational coordination

Amber Crist, Craig Robinson & Curt Lindberg (Cabin Creek Health Systems)

Country: USA

Cabin Creek Health Systems (CCHS), recognized as one of the United States’ most progressive and innovative primary care organizations, offers primary, rehabilitation and dental care to disadvantaged residents in rural West Virginia (US). It does so through a network of six primary care clinics and three school-based health centers. The organization is dedicated to improving the health and well-being of residents it serves. (West Virginia has some of the highest morbidity and mortality rates in the United States.) To help accomplish this leaders of the Clinic are constantly searching for means to more fully engage the expertise and passion of its personnel and offer gratifying work.

In late 2016 CCHS embarked on a comprehensive effort to increase the level of staff engagement in operational and quality improvement. The organization drew on insights from complexity science, Relational Coordination and results of a baseline Relational Coordination survey in crafting and carrying out this strategy. Elements of the strategy include:

• Creation of four learning networks – medical assistants, primary care and behavioral health providers, patient service representatives, and clinic leadership teams – that reach all clinic personnel. The networks are encouraged to be self-directing.
• Routine use of interdisciplinary clinically oriented case-based huddles to foster better patient care, learning and stronger ties among staff members
• The establishment of Project ECHO clinics (linking primary care teams with specialists through advanced videoconferncing) for hepatitis C, psychiatry, pulmonary rehab, medication-assisted treatment and chronic pain to advance capabilities of the staff to offer advanced care to patients with complex, difficult to manage health problems.
• Routine employment of Liberating Structures – simple to use meeting facilitation processes that build relationships, foster creativity and invite participation – in network and regular clinic staff meetings (examples of Liberating Structures are appreciative interviews, wise crowds, shift and share, 1-2-4-all, impromptu networking, and a specially developed Liberating Structure on RC mapping).
• Training of behavior health staff and Clinic leadership team members in Liberating Structures facilitation.
• Engagement of all clinics in an organization wide effort to address significant community health challenges, and use of Liberating Structures in meetings to address this issue.
• Education of all staff members in the seven dimensions of Relational Coordination.
• Regular coaching of Behavior Health staff and Clinic leadership team members on Liberating Structures use, and assistance in making sense of experiences with the use of these processes.
• Periodic sensemaking conversations in the learning networks, asking questions such as: how are we doing on our plans? what are we learning? what if any impact are Liberating Structures having on our meetings? how should we modify our plans given what we’re learning, what do the results from recent RC survey suggest about future priorities

Our presentation will elaborate on these strategies, detail the role Relational Coordination played in their development, report on implementation activities since the beginning of the initiative, detail changes in RC scores from baseline, and review lessons learned.

Track – Improving Healthcare Through RC Change Methods

 How a large healthcare organisation in Australia used relational coordination as an approach to improve relationships and outcomes in four multidisciplinary clinical teams

Darren McLean (Gold Coast Health)

Country: Australia

Context: Gold Coast Health (GCH) is a large Australian hospital and healthcare service employing approximately 8,500 staff. It serves a population of approximately 550,000 people and delivers a broad range of primary, secondary and tertiary health services. Recently GCH used Relational Coordination (RC) as an innovative approach to support two key strategic goals of the organisation: to deliver safe, effective and efficient quality services, and to continue a cultural improvement journey by investing in initiatives to sustain a work environment where staff are safe and proud to work.

Methodology: Relational Coordination (RC) was introduced and implemented into the organisation via a proof of concept program that began mid-2015 and concluded early 2017. Four multidisciplinary clinical teams participated, each with a particular focal work process in mind: General Medicine focused on the discharge process, Cancer Care focused on time from referral to the time of first treatment, Women’s Health focused on the management of the woman and baby of normal risk through pregnancy, birth and post-natal care, and Acute Young Adults Mental Health focused on the management of the consumer in the in-patient unit.

A novel five stage step-by-step implementation process was developed and used to guide the sequence of particular events. Broadly, this involved the formation of team-based leadership groups, identifying the focal work processes and respective work-groups, measuring RC using the RC Survey at two time points –T1 pre-intervention and T2 post-intervention, developing and implementing interventions designed to improve RC, sharing survey results with staff, and measuring a range a of selected quality and efficiency indicators pre- and post-interventions.

Findings: The T1 RC Survey was distributed to 658 staff with 370 completing the survey (a 56% response rate). The T2 RC Survey was distributed to 636 staff with 366 completing the survey (a 58% response rate). Comparative data from the T1 and T2 surveys indicated broad, but not universal, improvement in RC post interventions.

There were 53 post-T1 survey feedback sessions conducted in which 313 staff attended. There were 39 post-T2 survey feedback sessions conducted in which 208 staff attended. Qualitative data from these sessions generally supported the survey findings. Furthermore, staff positively viewed the way the RC process pays attention to team relationships and provides as safe space to discuss issues and opportunities. A negative was that staff did not always notice RC activities in the midst of many other change projects and quality improvement activities that were happening concurrently.

Mixed results were seen in terms of changes to quality and improvement measures, many of which were also impacted by other changes in the organisation that occurred during the time of this program. Evaluative feedback from organisational leaders indicates that the program was appropriate to the organisation’s goals, well run and should continue. Success factors and lessons learnt were identified which carry important implications for future practice.
We are interested in sharing and discussing the following:
• How we used a novel step-by-step implementation process to secure and sustain engagement with teams
• The outcomes of the proof of concept program
• The success factors and lessons learnt

Leading a multi-stakeholder change process to expand health service capacity in Oslo hospital

Jon Erik Borreson (Alaric AB)

Country:  Norway

This project sought to help an Oslo hospital expand its health services to meet growing patient needs. The scope of the project was to analyze and investigate if there is a possibility to utilize the current outpatient clinic, equipment and crew in a more appropriate and effective way so that it could handle the forthcoming expansions more or less within the existing premises. The theory and practice of Relational Coordination was used as main intervention model in the project.

A multi-stakeholder planning group was established with the following mandate: Describe today’s organization of Medical, Surgical and Rheumatological Clinics. Map the current use of the three outpatient clinics in terms of opening hours, number of patients, staffing plans, time spent, cancellations, use of equipment within today’s building stock.

One of the main issues the planning group faced were: centralized in one out-patient clinic vs distinct departments, but with some shared resources. How can the staff better coordinate around the patient?

The planning group discussed multiple topics that were to be addressed during a Relational Coordination Work-out conference. Multiple decision-making meetings with stake-holders in the top-management were completed prior to the conference so that topics were prioritized and right multi-professional teams were selected. Concrete solutions from the organization where to be presented to the top-management team on day 2 of the conference and it was crucial that the managers were prepared to make decisions “live” and commit themselves to these decisions after the work conference.
The most significant result from the conference was the decision of one out-patient clinic with a patient centered focus. Going from Medical, Surgical, Rheumatological departments to: Center for Musculoskeletal Disorders, Center for Gastrointestinal Disorders, Center for Cardiovascular Diseases, all with now working groups in progress led by top-management.

Three key learnings: First, organizational change is a struggle because resistance is so intense. Employees at all levels have difficulty seeing the system as whole. Working with an organization, you therefore need to warm it up – or unfreeze it. Genuine involvement is a key factor.

Second, when key-stakeholders in management turn down good initiatives, it’s important for employees to know and understand that the management has listened and understood. The warm-up gets everyone to a level of understanding about this where cross-collaboration is enhanced.

Finally, it is important to address expectations around the complexity of the problem and the time needed to remedy it. It’s important to emphasize that the problem is arising not because someone is not doing their job properly; rather it could be the result of a dysfunctional system. Performance of some individuals can be a product of a dysfunctional system. The focus is to work with the system as whole and focusing on work-processes. Also being persistent with key elements in RC model is vital.
It takes time to get managers to comprehend this and trusting the process of involving the system in a change process.

Supporting a “Fully Integrated Regionalized Microteam (FIRM)” model with relational coordination methods to optimize interdisciplinary team function on an inpatient medical service at a major US teaching hospital

Presented by Julius Yang (Beth Israel Deaconess Medical Center)

Co-Authored by Allison Wang & Amber Moore (Beth Israel Deaconess Medical Center)

Country: USA

In order to better engage and support our patients and families through a hospitalization, Beth Israel Deaconess Medical Center is introducing fundamental changes to interdisciplinary team structure, work process, and relational coordination on its inpatient medical services. Through collaborative efforts of the Department of Medicine and Patient Care Services, our inpatient general medicine service (approximately 100 total beds)will be reconfigured into interdisciplinary “microteams”, each staffed by an integrated team of doctors and nurses sharing a “pod” of 10-12 patient beds, to maximize “alignment” of physician-nurse patient assignments (change in structure). Once assembled into these “microteams”, our doctors and nurses will redesign workflows to maximize alignment and coordination of patient-centered activities, including a. interdisciplinary morning planning huddles, and b. communication and planning visits with patients and their families (change in work process). Finally, we seek to develop a high level of “relational coordination” and ultimately a “relational coproduction” of inpatient care within our microteam structure through a coaching/consultative engagement with Dr Gittell’s RC (Relational Coordination) group whose method applies a standardized approach to assessing, analyzing, and interpreting RC metrics in order to guide interventions to maximize effective patient-centered teamwork and communication. Underlying this framework is the assumption that in order to effectively partner with patients and families to meet their needs, our hospital staff need to achieve a high level of coordination between all of the disciplines (doctors, nurses, case managers, social workers, therapists, etc.) to address the unique challenges faced by each patient and family – thus relying on teamwork, rather than technology, to dispel patients’ and families’ anxiety, confusion, and frustration, allow them to regain a sense of control amidst the complexities of illness and hospitalization.

In conjunction with the above interventions we recognize the critical need for ongoing, specialized training in interdisciplinary teamwork skills (including meeting management, situational awareness, and shared mental models) to ensure our patient-centered microteams function at maximal efficiency and efficacy in partnering with our patients and families through the difficult course of hospitalization. In order to address this training need, a TEMPO program (“Training to Enhance Microteam Performance and Outcomes”) will be developed for implementation in conjunction with the changes in structure and process for the interdisciplinary teams on the inpatient medical services. This program will include both online/asynchronous independent training materials as well as live, facilitated, simulation-based training sessions focused on interpersonal dynamics to support a high level of relational coordination amongst our microteams, especially in terms of mutual respect, shared goals, shared knowledge, and effective communication.

In addition to RC surveys administered at the initiation of the FIRM model, we plan to administer a second survey approximately 9 months later to assess for significant change in relational coordination amongst the various roles impacting our patients’ outcomes and experiences. Furthermore, we plan to compare process (length of stay, time of discharge) and outcome (unexpected mortality, patient satisfaction, provider experience) metrics prior to and following introduction of the FIRM model and TEMPO programs, in order to assess efficacy and need for future revisions and/or improvements.

How and what to consider when setting up a new organization based on RC principles

Claus Jebsen & Sverre Roos Mangrud  (Institute for Co-Creative Leadership)

Country: Norway

A middle sized Norwegian municipality have decided to gather the major primary health care services at one location, defined as “Health – House” (HH). This institution will serve patients who do not need the specialized treatment of the hospital, but who are in need of care beyond what can be provided for at their primary home. The idea, a vision, is to create a seamless care/treatment process for the patient and their relatives.
The HH has six specialized units/wards (toxic & psychiatric, palliative, ER, short term, reinforced short term and rehab. In addition is medical service organized as a “flow” unit, serving all of the HH. There will be 69 beds and approx. 140 employees. The HH had been defined at the municipality’s “tool” for succeeding to provide high quality and efficient patient care. The management have decided that the HH be organized and run according to the RC principles, not only regarding the HH itself (internal collaboration) but also according to how the involved “external” collaborators collaborate to the best of the patient. Initially the HH has detected approx 30 unique organizations and institution for which collaboration is essential in order to provide high quality and efficient patient care. The actual number of collaborators are of course significantly higher since every institutions have multiple functions.

The HH has literally been constructed from the ide/vision, to concrete buildings, procedures and structures, work processes, hired staff and management, design services, define functions, arena for collaboration and sharing knowledge defining a boundary spanner role & fun etc. Employees arrive mid August and the first patient will be accepted from September.

At the RTC we will present how RC principles has been taken into account when constructing the new HH organization. We will look into structural, relational and work process interventions and set ups. We will define some of the problems and dilemmas that have been/must be solved. Furthermore, we will present our expectations when it comes to results, as well as how HH will do quality and efficiency assessments.

At the RTC our presentation will be from our perspective as consultants. However, we might also be able to co present with one of the leaders at the HH. This to be decided upon later.

Track – Strengthening RC Across Organizations

Facilitator: Karoline Bottheim, Lanka Consulting, Sweden


FaciliBo Vestergaardtating relational coordination between professionals working across three organizational silos with the same citizen – A tested structure and tools for managers, coordinators and project managers

Bo Vestergaard (Fair Process)

Country: Denmark

This practice-focused abstract is based on action research conducted in Esbjerg kommune/municipality, Denmark from September 2016- June 2017:

How to facilitate relational coordination between professionals working across three organizational silos with the same citizen?

The project involved 24 facilitators and 37 workgroups of 4-8 people, each focused on a citizen:

Findings: In order to strengthen relational coordination between professionals working with the same citizen/patient/family it takes: 1) a structured series of cross- functional meetings that 2) allow the right professionals to meet frequently enough to act timely and 3) these meetings must be facilitated – with a strong representation of visual tools – in order to create shared goals, shared knowledge and precise and problem solving communication and communication patterns know from the research in collective intelligence (Woolley, Chabris, Pentland, Hashmi, Malone. Science. October 2010)

Presentation of findings: I will introduce A) the simple sequential cross functional meeting-structure consisting of up to three types of cross functional meetings and B) the five central and highly practical tools for facilitating these meetings: Relational mapping, storyboarding, Set shared agenda/context, create collective IQ, Debrief (the short follow-up meeting).

An central finding about these tools is the visual principle: visual facilitation tools are highly helpful for active collaboration between all participant in the workgroup, creating progress, clarity on the shared goal and shared plan of action. Four of the five tools above are visual.

Research method: The facilitators has tested the sequential meetings-structure and tools mentioned above.
I have used the qualitative research method “storylab” to collect data from the facilitators. Especially about the meetings-structure, facilitation tools, effects and recommendations for what to keep/adjust (12 managers in the autumn of 2016 and 12 new facilitators in the spring of 2017 representing 12+25 facilitated workgroups. Each workgroup is focused on one citizen with a complicated case and touch points across 3 organizational silos in “Citizen & Labour”.

Altogether it is 4 x 3 hours of semi-structured interview (in October, December, May and June). Each interview results in a small report and learning/suggested adjustments are put to action.
How is the research meetings conducted? The researcher place a question and the participants write an answer on a card (in order not to evoke group-think) before the researcher interviews into each participant´s answer (2-3 minutes pr. participant).

Ninna MeierCreating coherence – A multi-level theory of relational organizational change

Ninna Meier (Aalborg University)

Country: Denmark

In this presentation, we share data from a multi-level process study of organizational change, whose purpose was to improve coherence of patient care through connecting leadership and coordination practices across levels of management and across systems of care. This collaborative interventional study of organizational change was carried out through a three-stage methodology: 1) in depth interviews and observations of existing work practices, 2) recurring seminars to share results with participants, and 3) in depth interviews and observations of organizational interventions that were designed by the participants to create coherence.

We show how efforts to achieve coherence play out dynamically at multiple levels, including front line care providers, clinical managers, ward managers, and hospital managers and we demonstrate how such efforts are connected through actors’ attention and intention to creating coherence. We find that creating coherence is a matter of creating continuous organizational change on multiple levels, because coherence in the clinical micro system is an ongoing achievement, embedded in structures, role relationships, routines and ad hoc coordination practices including articulation work. Moreover, we propose that these elements need to be connected, woven together and aligned across levels and providers.

In conclusion, we propose a multi-level relational theory of organizational change that includes relational, work process and structural interventions. Our contribution is to extend relational theories of organizational change to address the coordination challenges that arise when work is increasingly distributed across care providers and over time, and to identify the role that relationships and structures play in the ongoing achievement of making healthcare work coherent.

The iMuhammad Siddiquempact of relational coordination on project success – A case of construction projects at Institute of Management Sciences, Pakistan

Muhammad Siddique, Zahoor Khan & Hamza Khwaja (Institute of Management Sciences, Peshawar)

Country: Pakistan

This study aims to determine the impact of relational coordination on project success. Researchers in the field of relational coordination have largely supported the view that coordination that develops through frequent, high quality communication supported by relationships of shared knowledge, shared goals, and mutual respect facilitates organizations to better accomplish their desired performance (Gittell, 2006). Complexity of projects in Pakistan and construction projects in particular necessitates an approach that should be coordinated in order to reach the project designated milestones for success. Project centric environment are different from organizational culture and are therefore, considered challenging due to its own sets of norms and goals for project success. This study focuses on this area of research by examining the role of relational coordination in the success of construction projects.

Relational coordination model explains that in highly interdependent work settings, team members that engage in timely, accurate, frequent and problem-solving communication with each other also have a high level cohesion in terms of shared knowledge, goals and mutual respect results in better performance. These are also the characteristics of a project culture where project is required to be completed within due time, in a cost efficient and defined scope to achieve desired results.

This study has been conducted in the construction sector of Pakistan. In a sample of 100 respondents from 6 construction projects, primary data was gathered in the form of project team members’ perceptions about relational coordination during January-March 2016. The perceptions of Project directors, coordinators, engineers, accountants, consultants, managers, and contractors working in various functions provided useful insights in determining the effects of relational coordination on project performance.
Relational coordination was measured using seven item RC survey of Gittell (2001). Project success was measured through Nguyen & Ogunlana (2004) four categories “4 coms” model including project success factors of comfort, competence, commitment and communication categories. The comfort component emphasizes stakeholders’ involvement in the projects. Competence focuses on utilizing up-to-date technology; emphasis on past experience; presence of competent teams; and awarding bids to the right contractors. Commitment emphasizes the need for a strong management, clear objective and scope. Communication focuses on shared and collective vision about the project at all levels.

Results have shown support for the research hypotheses suggesting that relational coordination among project team members at various functions has a positive and significant impact on project success. It was found that project coordinators and engineers have higher relational coordination than other functions. One of the most significant findings emerged from this study is that relational coordination was acknowledged as a formal process that effect project performance.

The findings from this study contribute to the existing literature on relational coordination and project performance, showing how relational coordination can affect the performance of projects. The implications of this study suggest that as important stakeholders, both project directors and project consultants along with project coordinators should be involved in the design and implementation of work systems and plans for achieving higher performance. Future studies should focus on social sector projects.

Using rLauren M. Hajjarelational coordination as a framework and intervention to support collaborative policing and improve crime outcomes

Lauren Hajjar (Brandeis University)

Country: USA

Efforts are currently underway to better understand how enhanced collaboration impacts crime outcomes, specifically through the BJA’s Smart Policing Initiative. Law enforcement collaboration and engagement with their communities would benefit from a more measured and coordinated approach. However, there is currently no systematic methodology for assessing or strengthening these connections. Stronger relational coordination between police departments and the communities they serve has potential to address these gaps and can support the Collaborative Policing Framework. We propose a study to test a tool and framework to increase collaboration between law enforcement agencies and the communities they serve. The framework is Relational Coordination (RC) Theory, supplemented by the Relational Model of Organizational Change and integrated into the Collaborative Policing Model. The unbounded and validated tool is the Relational Coordination Survey. The purpose of this proposal is to explore RC as a framework, diagnostic tool and intervention that supports Collaborative Policing and to gain insight into potential research designs and sampling methods to test the impact of RC on crime outcomes.

Design thinking in the Boston Mayor’s Office of New Urban Mechanics

Presented by Kimberly Lucas and Jaclyn Youngblood (Mayor’s Office of New Urban Mechanics, City of Boston)

Co-Authored by Stephen Walter, Susan Nguyen, Sabrina Dorsainvil, Max Stearns, et al (Mayor’s Office of New Urban Mechanics, City of Boston)

Country: USA

The Mayor’s Office of New Urban Mechanics (MONUM) is the City of Boston’s research + development team. We believe that civic innovation is more than just increasing government efficiency. It is also about improving the experience and well-being of our residents and visitors. A democracy is sometimes messy, unpredictable, and playful — all for good reason. So, we ask: how can we make civic life more meaningful for more people?

With the Mayor’s backing, we work with both internal and external partners to make people’s experience of the City of Boston a more delightful one. Our projects range from humanizing the experience of getting a pothole filled to improving the experience of paying a parking ticket in City Hall to providing the kinds of nutritious meals public school students are interested in eating. We employ a range of qualitative methodologies to learn more about the wants and needs of the City’s residents, employees, and tourists, and then we engage a range of stakeholders to create the context(s) in which pilot projects or prototypes might be feasible to implement. As a team, our backgrounds are diverse, allowing us to draw from a range of skill sets to ensure that projects get done.

As part of this presentation, we envision sharing and discussing our methodologies and the theories and principles that inform how we operate. We would also like to discuss specific examples from our work that demonstrate how we help the City of Boston create more meaningful civic spaces.

Track – Understanding RC Change and How to Sustain It

Facilitator: Micha Kaempfer, walkerproject, Switzerland

Tony Suchman
Understanding the impact on personnel and the underlying mechanisms of relational coordination

Presented by Tony Suchman (Relationship Centered Healthcare)

Co-Authored by Curt Lindberg (Billings Clinic)

Country: USA

Billings Clinic, an integrated healthcare system serving Montana, Wyoming and the Dakotas, has considerable experience with Relational Coordination (RC). The framework and the survey have been employed to inform improvement in numerous areas

To help gauge the impact of RC on the Clinic as well as the factors that led to improvement, semi-structured interviews were conducted with twenty-one staff members. Using qualitative methods the interviews were analyzed and major themes were derived. These themes and a supporting quote are shown below. They will be explored at the Roundtable.

• RC is a new paradigm that deepens understanding of dynamics in teams and organizations: RC leads to an appreciation for the interdependencies and interconnections inherent in organizations, the significance of systems and their complexity, the value of diverse perspectives, the impact that one can have on the larger system and how change progresses in an organization.
o “RC is a school of thought. If you shift your paradigm it changes how you view the world. It has changed how I approach everything in my job.”

• RC informs actions to improve collaboration: RC stimulates efforts to be inclusive, bring in diverse perspectives, understand the work of others, build relationships and avoid blaming others
o “Before my exposure to Relational Coordination I thought I had a pretty broad view of things, but didn’t feel I had permission to inquire about the work others do….Now I do inquire, and I use the dimensions of RC to inform my inquiry. This practice, I’ve found, deepens relationships.”

• RC paradigm and actions foster personal development and fulfillment: Knowledge of RC paradigm and experience with RC-informed improvement leads to personal development, greater confidence, fulfillment and pride in one’s contributions
o “Billings Clinic has given me the opportunity to grow and learn by exposing me to RC and enabling me to bring my RC experience to other departments. I love my work with RC and can’t believe I get paid for it.”

• RC paradigm and RC-informed improvement activities positively impact the organization: RC initiatives have heightened collaboration within and across disciplines, led to diffusion of RC efforts across the organization and stronger connections with employees, who speak of their pride in the organization for support of RC, which together lead to better patient care.
o “A big benefit in the ICU is better teamwork. As we move on new project, like delirium prevention, people reach out and express their desire to be involved and feel comfortable and safe to make contributions. The result, I expect, will be better patient outcomes.”

• RC presents new challenges for leaders and staff: Those leading RC initiatives found it challenging to make RC language understandable, help colleagues come to terms with the emergent nature of RC-informed projects, and engage all the staff suggested by the inclusive principles of RC.
o “I’ve noticed that some managers and leaders struggle with the process. I think this is because RC is not a linear, straightforward, mechanistic process that comes with a clear set of prescriptive steps. How to overcome this hurdle and help people become comfortable with a process that is learning based and emergent is a challenge.”

FaJim Bestctors and processes underlying increases of relational coordination in task-coordinating groups

Jim Best (Saybrook University)

Country: USA

Project: This exploratory case study casts light on both how we build relational coordination (RC) in groups and how we might sustain RC by looking at the particular experience of an Intensive Care Unit (ICU) at a healthcare organization in the Midwestern United States. Specifically, it addresses the research question of how and why interventions there contributed to increases in inter-role RC.

Context: RC Theory asserts that RC increases drive positive outcomes of quality, efficiency, safety, and worker and client well-being. The theory also asserts that organizational structures have a moderating effect on that relationship. Numerous studies support the correlation with outcomes (Gittell & Logan, 2015) and a body of work has shown three types of interventions can cause increases in RC. The RC Model of Organizational Change describes some of these dynamics. Less work of a qualitative nature has been done directly on how and why the interventions produce these effects. More granular theory may contribute to more effective intervention design.

Method: RC Surveys were used to identify the most interesting ICU role relationships. ICU participants (15) in those roles were interviewed including change agents (2). Rounds and meetings were observed. This data was compared to interviews with the perspective of expert consultants (8) doing this type of work across multiple sites.

Findings: ICU care provider interviews revealed a complex mesh of interconnected dimensions underlying increases in RC, yet displayed a remarkable consistency in how they were woven into five basic inter-related themes–opportunity tension (opportunity + motivation), relational factors, focal activity, sensemaking, and contextual factors.

Supportive leadership at multiple levels was required to hold the necessary “whitespace” (physical, temporal, resourced, safe, power-leveled) to allow purpose, action, reflection, and innovation to unfold. Activities required interaction where participants were heard, seen, and respected by their peers. Norming around respect and effective communication was pronounced. Structures that captured these norms were key to sustainability and a sense of forward progress. The resulting high-quality connections between people and between roles enabled the safety and resiliency for information flow and learning as a cultural norm to flourish. The opportunity participants saw in general (and highly motivated champions in particular) across scale from micro to macro-moves coupled motivation and purpose to larger and less specific shared goals. Consultants’ perspective of their own experiences at a variety of sites echoed those at the study site. Additionally they noted that RC theory resonates as a sensemaking framework, seeing the integrated task workplace as a system helps workers place themselves within it leading to transformative shifts from “Me” to “We,” and change takes time. Change happens along many dimensions incrementally and episodically. The RC index may not always detect positive changes in relational capacity. A pattern language of design factors that can be strung together for specific change initiatives may be a useful direction that emerges.

BuildCurt Lindberging a Billings Clinic learning health system informed by relational coordination

Presented by Curt Lindberg (Billings Clinic)

Co-Authored by Randy Thompson, Robert Merchant and Jennifer Potts (Billings Clinic)

Country: USA

Creation of Learning Health Systems (LHS) is advocated by the U.S. Institute of Medicine (IOM) as a way to “produce high-quality health care that continuously learns to be better” and “provide Americans with superior care at lower cost”. Most LHS literature focuses on information technology and the infrastructure needed to capture, analyze and disseminate data in the learning process.

Interest in Learning Health Systems at Billings Clinic emerged as an outgrowth of the organization’s efforts to employ insights from complexity science. to improve care and organizational performance. Together, nurses, physicians, researchers, therapists, and leaders formed a Learning Health System Network to advance learning and improvement capabilities at the Clinic. Early in its development work, the group discovered there was scant attention in the LHS literature on the actual process of learning and how it can be cultivated.

This presentation reports on the work of the Network to rectify this oversight. Drawing on literature from complexity science, social psychology, human development, organizational psychology, self-determination theory, extensive experience with Relational Coordination as a framework for understanding and guiding change, and results from a series of semi-structured interviews on engagement in improvement work with a purposive sample of 127 Billings Clinic staff members, a set of learning principles was created to guide effective learning and support learning health system development. Consonance between the literature, experience and the interview findings bolstered confidence among LHS Network members in the six principles and their suitability for use in the organization. These principles were also created to catalyze conversations about a deeper, more nuanced understanding of the unexamined core of Learning Health Systems—learning—within the worldwide LHS community.

• Draw on wisdom of groups and value connections
• Embrace sense making over decision making in dealing with the unexpected
• Bring diverse perspectives and strategies to complex challenges
• Animate people, provide direction, update regularly and interact respectfully
• Appreciate the power & ubiquity of emergent change and the limitations of planned change
• Concentrate on small wins and characterize challenges as mere problems

The learning principles that emerged are beginning to impact how Clinic personnel think about and approach challenges and change. They are informing choices on new clinical programs and improvement processes. Resulting initiatives, which arose contemporaneously with LHS explorations and represent new approaches to learning – Relational Coordination, Project ECHO and Safe & Reliable Healthcare – are spreading rapidly across Billings Clinic, illustrate the principles in action and represent movement towards a more robust learning culture and a learning health system at Billings Clinic.

Lessons learned in transferring the organizational model of change into practice – A teaching workshop

Ken Milne & Nancy Whitelaw (Salus Global)

Country: Canada

The authors will share their cumulative experience in leading transformational, sustainable performance change in the healthcare working environment. They will outline five key generic elements that have helped workgroups overcome challenges and achieve success in performance improvement.
Their observations are based on the amalgamation of an extensive review of social organizational behavioural review studies with shared narratives of real work case experiences. Their application of this knowledge gained from the literature into their own work experience in a number of projects with a variety of clients has resulted in the emergent identification of five key factors that are essential in leading groups through sustainable performance change projects.
These five factors span the scope of engagement from initial contact, with learning and understanding the client, expectations of the clients, the organizational structure and work processes within the work environment, pre-conditioning, orientation to the change process, implementation of the project, evaluation of achievements, and staying closely engaged with the client throughout the project.

The authors will use illustrations from published literature and from their own work experiences. They will propose a simplified process to use in leading a group through a performance change process.

During the presentation they will engage the participants with some group exercises that they have found helpful to move groups forward in their organization’s change projects. There will also be opportunity for dialogue with participants to share their own experiences in leading performance change.