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Organizations as Machines, Organizations as Conversations: Two Core Metaphors and Their Consequences
Abstract
One factor contributing to the limited success of organizational change initiatives is the use of an outmoded conceptual model: the organization as machine. This metaphor leads to the creation of detailed blueprints for desired changes; invites unrealistic expectations of control; and creates anxiety, blame and defensiveness when events inevitably do not proceed according to plan, thus hindering the work. An alternative conceptualization--the organization as conversation--portrays an organization not as a reified object upon which we can act but as self-organizing patterns of thinking (organizational identity and knowledge) and relating (organizational culture) that exist in the medium of human interaction in which we participate. Principles of complexity dynamics (self-organization) have important implications for organizational change practices. (1) Organizational change requires mindful participation--reflecting on and talking about what we are doing together here and now, what patterns of thinking and interacting we are enacting, and what new behaviors might interrupt old patterns or give rise to new ones. (2) Diversity and responsiveness favor the emergence of novel patterns. Skilled facilitation can enhance these characteristics when novelty is desirable; checklists and protocols can diminish these characteristics when consistency and reliability are needed. (3) We cannot know in advance the outcomes of our actions so we need to hold plans lightly, value "not knowing" and practice emergent design. The organization-as-conversation perspective also has important implications for T3 translational research, redefining its purpose, suggesting new methodologies, and requiring new approaches for evaluating proposed and completed projects.
... Prescriptive ethics places major emphasis on the individual as the main decision maker and the responsible agent for what happens in organizations (Kotze, 2002). Such codes are becoming obsolete as this understanding of ethics is close to the model that views organizations as machines (Suchman, 2011;Gergen, 2016). This metaphor has its roots in the industrial revolution, where factories offered the model for prediction and control. ...
... Looking at an organization as a closed system centralizes the physical space, where the roles and tasks of facilities and departments are emphasised over people and their relationships. According to Suchman (2011), this approach to organizations is not aligned with the latest needs of our fast-changing world. Suchman (2011) suggests a shift from looking at an organization as an entity (e.g., a physical place) to looking at an organization as a conversation. ...
... According to Suchman (2011), this approach to organizations is not aligned with the latest needs of our fast-changing world. Suchman (2011) suggests a shift from looking at an organization as an entity (e.g., a physical place) to looking at an organization as a conversation. Viewing an organization as a conversation opens us to embrace the notion that an organization is a complex system in which people are in constant interaction. ...
... Effective change leaders excel in engaging others in the co-creation of a desired future, one conversation at a time. 7 They pay close attention to the interests of others, aligning change initiatives with stakeholders' needs and values, and help others tolerate the fears and losses that accompany change. 3,8 They also pay attention to their environment, building strong partnerships and leveraging serendipitous opportunities for collaboration and expanded impact. ...
... This dynamic participative model recognizes that big patterns of organizational behavior (such as power relations and culture) are created continuously in the small moments of everyday interactions, so it promotes mindfulness of how leaders and others are behaving in each moment and the relational patterns they are enacting. 7 It invites the thoughtful introduction of small disturbances in the patternschanges in thinking and behaviorthat might then cascade to become transformative changes. The model also acknowledges the fears and losses that are intrinsic to change processes. ...
... Instead, it often starts as a series of small local changes, both planned and unplanned, which amplify and spread until, after reaching a tipping point, they gain sufficient momentum to become the new normal. 7 One lesson learned is that the social side of leading organizational changea complex and multifaceted topiccan indeed be taught and that skills training can make a difference. The current gap in leadership practice that hinders change initiatives can be filled. ...
•Despite the urgent need for transformative change throughout healthcare, many change projects fail to achieve their objectives, often because of interpersonal and behavioral factors that are beyond the training and experience of most change leaders.•Contemporary theories redefine the work of leading organizational change from handing down a comprehensive control-oriented blueprint to engaging everyone in creating and bringing to life a shared vision for change.•It is possible to foster enduring changes in how leaders approach the social dimensions of organizational change in a program of relatively modest duration. A 96-hour program integrating contemporary theory, skill practice and personal reflection was associated with significant self-perceived changes in leadership behavior and organizational effectiveness.
... They may seek change or to avoid change. In this sense human beings, and the interactions between human beings, may be un-modellable, and the system metaphor may not be useful (Bovaird, 2008;Stacey and Mowles, 2016;Suchman, 2011). Stacey and Mowles (2016) critique the living system metaphor on the basis that "organisations are not things at all, let alone living things. ...
... Systemic perspectives, on the other hand, encourage us to think of organisations as machines, or living systems, boundaried from their environments. Suchman (2011) contrasts the value of regarding the organisation as a machine vs regarding the organisation as a collective conversation. The latter metaphor discourages us from thinking about the organisation as a reified object and encourages us to notice self-organising patterns of thinking and relating. ...
... Simultaneously, the team was beginning to consider alternative explanations for the results from the first year and developing a hunch that proved to be the key to unlocking the eventual approach to reducing the falls rate. This hunch went beyond locating responsibility for reducing falls primarily with ward leaders and was informed by insights from improvement methods inspired by complexity theory (Suchman, 2011). ...
... This allowed opportunities to identify and utilise emergent patterns and ideas. The concept assumes there is no 'silver bullet'; small changes are continuously introduced hoping that some will have a ripple effect and encourage other changes (Suchman, 2011). Another similar approach of 'try a lot of things, keep what works' has been found to be the basis for sustainable success in larger corporations (Collins and Porras, 1994). ...
... Simultaneously, the team was beginning to consider alternative explanations for the results from the first year and developing a hunch that proved to be the key to unlocking the eventual approach to reducing the falls rate. This hunch went beyond locating responsibility for reducing falls primarily with ward leaders and was informed by insights from improvement methods inspired by complexity theory (Suchman, 2011). ...
... This allowed opportunities to identify and utilise emergent patterns and ideas. The concept assumes there is no 'silver bullet'; small changes are continuously introduced hoping that some will have a ripple effect and encourage other changes (Suchman, 2011). Another similar approach of 'try a lot of things, keep what works' has been found to be the basis for sustainable success in larger corporations (Collins and Porras, 1994). ...
This article describes a 10-year programme of work that has reduced inpatient falls rate by 46% and how this improvement has been sustained. The methodology applied in this initiative has forced one Trust to challenge expectations about the inevitability of patient falls in hospital. This initiative has resulted in approximately 568 fewer falls each year. Based on costings from NHS Improvement, the estimated 5108 fewer falls between 2011 and 2019 have saved the Trust £13.3 million.
... Given the scale, range and diversity of interconnected elements involved in the production of population health, healthcare, community and social care services the complexity approach offers apt resources with which to better understand and manage change. It takes adequate account of the emergent, self-organising and unfixed nature of change (Suchman, 2011;Puustinen and Lehtimaki, 2016), its instability and contested status (Shore and Kupferberg, 2014), the often hidden unfolding of its patterns (Montgomery, Doulougeri and Panagopoulou, 2015;Baker, Suchman and Rawlins, 2016) and the awareness that 'command and control' modes often elude health system managers working where no one perspective or oversight is possible (Heldal, 2015). The unpredictability of change is taken into account in the change process so that managers and change agents must develop the skills of working well with ambiguity, paradox and uncertainty (Till, Dutta and McKimm, 2016). ...
... This has resulted in a focus on the many complexities of organisations including teams, service settings, task profiles and roles (e.g. Ranmuthugala et al, 2011;Chreim and MacNaughton, 2016) as well as the challenges of implementation, knowledge transfer and working with long established structures and patterns of work (Suchman, 2011;Dearing et al, 2011;Rycroft-Malone et al, 2016;Oborn, Barrett and Racko, 2013). In global terms the goal of this work is identifying, understanding and generating organisational and system changes in response to the challenges of public expectations for universal access to health and social care; for safety, quality, efficiency and affordability. ...
Critical analysis of the literature underpinning the formal change management approach of the Health Services Executive in Ireland. This review is a support document to the HSE's Change Guide, 'People's Needs Defining Change' People’s Needs Defining Change – Health Services Change Guide (2018) Caitríona Heslin and Anne Ryan, Organisation Development and Design, Health Service Executive (HSE), Kells, Co Meath
... While these views have been available for several decades now, they have received little translation into listening pedagogy. This may be due to the fact that a focus on conversation involves acknowledging the self-organizing, simultaneously influential dynamics of multiple entities interrelating in somewhat unpredictable ways with each other (Suchman, 2011). The relational forms of social constructionism described above do not propose that listeners and speakers deliberately formulate responses and utterances at every conversational turn. ...
Positive Organizational Scholarship (POS) perspectives define interpersonal work experiences such as positive work relationships and high-quality connections by the mutual growth and empowerment experienced by relationship or connection partners. Listening has been implicated as a key mechanism for building such positive interpersonal work experiences, but it is unclear how listening spurs on mutual, rather than one-sided growth, in relationship and connection partners. In this paper, we argue that management education currently focuses on the intrapersonal capability of listeners to execute key verbal and non-verbal behaviors. Less emphasis is placed on the mutual experience co-created between speaker and listener and, thus, on the potential for mutual growth and empowerment. We articulate what “being relational” in the listening experience means, and use experiential learning theory to articulate how educators might create learning spaces for “being relational” through conversations between listener and speaker. Throughout the paper we contend with issues of individual and structural power asymmetries inherent in understanding listening as a relational process.
... CAPA and modal dialectics A figure representing the functionality of CAPA (Figure 1) shows how the modal dialectic works. Learning and change are de-centred or distributed so that no single centre, individual, group or unit has full view or control of what is going on; all participants become players as the command and control paradigm is destabilised 76 . The four modes identified as topical, ecological, dialogical and pragmatic are the forces driving activity and change in a cyclical or spiraling feedback loop. ...
Background: This concept paper presents Contextual Analysis for Practical Action or ‘CAPA’ as an action-oriented tool to understand and implement interventions in real-life service delivery contexts. Understanding how contexts work is a critical challenge for Health and Social Care Systems seeking to become more integrated. CAPA is a tool for understanding and empowering agents in local contexts. The local context is understood here as a key factor in implementation success. This concept paper offers rich theorising to underpin the translation of systems reform initiatives into meaningful local engagement and change.
Methods: Analysis of the ‘implementation conundrum’ highlights the problem, while a review of the organisational learning literature identifies ‘sensemaking in organisation’ as a powerful mechanism to address it. Based on earlier phenomenological research the dynamics of organisational sensemaking are presented. Finally, applications for CAPA are explored and next steps outlined.
Results: CAPA makes tangible the implicit and interpretive nature of organisational life as ‘sensemaking in context’. This phenomenon is analysed as a determinant of implementation success. As such, CAPA opens a path to working with contextual complexity by framing it as a dialectic pattern of topical, ecological, dialogical, and pragmatic modes that ‘contextualise’. CAPA is a tool for researchers and practitioners to explore the complexity of local contexts and their implementation challenges, and working-with local agents for learning and change.
Conclusions: Health reform needs new approaches for understanding implementation in context. CAPA is a tool for understanding and working-with contextual factors central to the complexity of policy or knowledge translation for example. This paper outlines its rationale, principles, and functionality. Possible applications are explored for co-designed practical learning experiences. It concludes with a call to policy makers, service managers and researchers to use the approach in specific settings so it can be developed and refined.
... As humans are relational, and have needs that change with circumstance and context, such expectations are unrealistic and "profoundly unhelpful" (Kitson, 2009, p.217). Human service organisations are better viewed as networks of interpersonal relationships and meaning (Kitson, 2009;Grant, Mills, Bridgeman & Short, 2006;Hughes & Wearing, 2013;Suchman, 2001Suchman, , 2011. ...
... 21 Although the learners do not always get to choose the goal, they must have some control of the process of learning and how they will achieve the goal. 52,54 Bidirectional communication between leaders and learners throughout this process is critical to ensure that the vision of the future state is clear and that the concerns or reservations of the learners are understood and appreciated. Although this inclusive approach is slower, such involvement is critical to implementing and internalizing the new norms and values and incorporating them into the existing culture. ...
The past decade has been a time of great change for US physicians. Many physicians feel that the care delivery system has become a barrier to providing high-quality care rather than facilitating it. Although physician distress and some of the contributing factors are now widely recognized, much of the distress physicians are experiencing is related to insidious issues affecting the cultures of our profession, our health care organizations, and the health care delivery system. Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized. When challenges with culture arise, they almost always relate to a problem with a subcomponent of the culture even as the larger culture does many things well. In this perspective, we consider the role of culture in many of the problems facing our health care delivery system and contributing to the high prevalence of professional burnout plaguing US physicians. A framework, drawn from the field of organizational science, to address these issues and heal our professional culture is considered.
... Suchman [19] proposes conceptualizing an organization as a set of conversations. This model, he argues, allows the change leader to think of organizational change as something that requires mindful participation instead of having an unrealistic expectation of control. ...
Reducing healthcare-associated infections often requires the use of both technical and adaptive strategies. The experiences of Semmelweis and Nightingale teach us the importance of social adaptation of technical interventions. Because most infection prevention interventions require widespread participation by healthcare personnel, it is helpful for infectious diseases physicians to learn principles of diffusion of innovations theory and apply them to influence different groups. Comprehensive unit-based program has been successful in reducing device-associated infections. Positive deviance as a socioadaptive approach may be promising. These and other approaches such as social network analysis, relational coordination, link nurses, and stop the line policies need to be further evaluated in future studies. Future research on socioadaptive interventions needs to focus on developing tools and strategies for diagnosing local context and study how these interventions might influence culture of safety. Strategies to sustain momentum of improvement efforts in different healthcare settings need to be refined and further developed through additional research.
... Unlike the product of manufacturing, patients cannot be considered to be stuff, or indeed simply a medical condition, to be processed or acted upon. Principles of complexity dynamics describe a conceptual model of the organization as a conversation instead of a machine which emphasizes self-organizing patterns of relating and thinking in the course of human interaction (Suchman, 2011). This inter-connected relationship of staff and patients behoves us to consider how we deliver design for a holistic health care service. ...
Service design provides the means to make sense of the complex interactions and processes experienced when delivering and receiving patient care. The tools of service design generate visual narratives that communicate experiences of and interactions between medical staff, hospital patients and carers, as well as mapping processes and systems and identifying the nature of relationships between the various stakeholders involved. Often service design tools are used to communicate what was observed and what might be done, but when used as analytical and diagnostic tools, they deliver a powerful means of sharing thinking and decision-making across a wider community beyond the designers themselves. The authors discuss the application of human-centric service design, not only as the means to design innovative service outcomes but to analyse and diagnose the complex processes involved in delivering patient care. The utilisation of this multifaceted design process resulted in richer service prognosis and propositions in concordance with the needs of patients, carers, hospital staff and clinicians than often provided by the more routine qualitative or quantitative analysis of service delivery. Using case studies of projects undertaken at University Hospital Crosshouse to illustrate our findings, this chapter explores the issues encountered during the application of service design and service thinking by clinical and non-clinical professionals, including the lessons learned in developing sustainable innovation practices that reduced reliance on the presence of designers. We highlight the dynamics of this approach, looking through the lens of person-centred service design and open innovation, how staff and service users engaged in exploring new insights and approaches.
... This change calls for managers' and employees' efforts to participate in developmental work with reflections about what could be done jointly. Then new patterns of thinking and behaving can be developed in the organization [36]. It is important for managers to understand and respect that contradictory opinions can exist at the same time in the same organization [37] in order to facilitate the process of change. ...
Background
Implementing the value-based healthcare concept (VBHC) is a growing management trend in Swedish healthcare organizations. The aim of this study is to explore how representatives of four pilot project teams experienced implementing VBHC in a large Swedish University Hospital over a period of 2 years. The project teams started their work in October 2013. Methods
An explorative and qualitative design was used, with interviews as the data collection method. All the participants in the four pilot project teams were individually interviewed three times, with interviews starting in March 2014 and ending in November 2015. All the interviews were transcribed and analyzed using qualitative analysis. ResultsValue for the patients was experienced as the fundamental drive for implementing VBHC. However, multiple understandings of what value for patients’ means existed in parallel. The teams received guidance from consultants during the first 3 months. There were pros and cons to the consultant’s guidance. This period included intensive work identifying outcome measurements based on patients’ and professionals’ perspectives, with less interest devoted to measuring costs. The implementation process, which both gave and took energy, developed over time and included interventions. In due course it provided insights to the teams about the complexity of healthcare. The necessity of coordination, cooperation and working together inter-departmentally was critical. Conclusions
Healthcare organizations implementing VBHC will benefit from emphasizing value for patients, in line with the intrinsic drive in healthcare, as well as managing the process of implementation on the basis of understanding the complexities of healthcare. Paying attention to the patients’ voice is a most important concern and is also a key towards increased engagement from physicians and care providers for improvement work.
... By contrast, the study of organisational systems often conceptualise the organisation as a machine. An alternative approach, drawing from dynamic open systems theory portrays the organisation as a series of conversations, of human relationships [21]. This view sees large scale change emerging from everyday behaviours and interactions. ...
This paper argues that insights into infant emotional development, particularly the capacity to engage with rupture and repair, can be applied to the understanding and promotion of flourishing in later life, individually and socially. Starting with the Queen's visit to the Republic of Ireland as an example of successful social repair after rupture that enables flourishing, the paper goes on to outline some relevant psychological theory that undergirds this. It then considers some of the practical relevance and problems that apply to rupture and repair in the contemporary world, particularly the world of health care, Amidst the inevitable messiness of life, flourishing and growth can only be achieved with the kind of flexibility implied by creating repair in the face of rupture.
... The metaphor of organization as conversation recognizes the organization as a set of dynamic patterns of thought and behavior that cannot be separated from the realities of human interaction. This is in contrast to the common metaphor of organization as machine, a set of blueprints that aim for control (Suchman, 2011). Trying to perfect the organization as a machine only creates stress, blame, and defensiveness when events inevitably stray from the plan. ...
This article introduces the concept of activation and discusses its use in the implementation of global operating models by large multinational companies. We argue that five particular activators help set in motion the complex strategies and organizations required by global operating models.
... Stage 3 is where innovative processes, such as interprofessional bedside rounding, are measured, assessed, scaled, and disseminated to new settings-essential steps in process improvement. In contrast to randomized controlled trials, the gold standard for research at stages 1 and 2, assessment at stage 3 must carefully examine, rather than exclude, rich accounts of the local, contextual factors that determine success or failure in the real world of practice [19,20]. We are assessing the Macy project with narratives and surveys of learners, teachers, and patients. ...
Over the past 3 decades, teaching rounds have drifted away from the bedside in favor of management discussions in a conference room or hallway. As a result, patients and families-2 of the most valuable resources in health care-are being left out of the loop. This trend is now being reversed by bedside presentations of newly admitted patients and structured interdisciplinary bedside rounds.
... This would be a concrete way to adopt and unify the visionary ideals recently proposed by Carroll [11], Fischer [17] and de Souza [14]. But it also means, more importantly, to shift from an idea of IT as technology of control, to an idea of technology supporting conversations [29,30] and human relationships. This would give again back responsibility to the users, now treated as mere consumer of an information and computation-based megaservice [26]: participation, then, as an opportunity to exert responsibility, active engagement and awareness of how a community can mobilize resources to shape a better future: as a return to "care" as the leading concept behind IT development and use [3]. ...
... Current healthcare systems, including nursing, are complex, multiprofessional and constantly changing. Therefore, health services can neither be understood as enclosed mechanisms nor can they be operated in a vacuum (Plsek & Greenhalgh 2001, Uhl-Bien & Marion 2009, Benham-Hutchins & Clancy 2010, Suchman 2010; instead, they interact as a complex whole. The complex adaptive system (CAS) model, with roots in system theory, is a modern theoretical framework for studying healthcare systems (Anderson 1999, Clancy 2007, Paina & Peters 2012, Vardaman et al. 2012). ...
AimsThis study sought to analyse relationships between nurse staffing and patients’ length of stay in acute care units and to determine whether non-linear relationships exist between variables.Background
Healthcare systems are complex and it could be assumed that they comprise non-linear associations. However, current planning and evaluation of nurse staffing are based primary on linear reasoning.DesignThis quantitative study adopted a retrospective longitudinal design.Method
Retrospective register data, consisting of information relating to 35,306 patient episodes and administrative information concerning 381 nurses, were used. Data were collected in 2009 from 20 somatic inpatient units at a university hospital in Finland as a monthly time series of 2008 data and analysed using Bayesian dependency modelling.ResultsPatients’ acuity was the most important agent that connected all eleven variables in the dependency network of nurse staffing and short length of stay. Non-linear associations were found between short length of stay and the proportion of Registered Nurses. Skill mix consisting of an average proportion of Registered Nurses (65–80%) was conducive to a short length of stay and predicted a 66% likelihood of short length of stay. Higher and lower percentages of Registered Nurses predicted lower likelihood of short length of stay.Conclusion
Flexible nurse staffing is preferable to fixed staffing to provide patients with shorter length of stay in acute care units. In the present research, the Bayesian method revealed non-linear relationships between nurse staffing and patient and care outcomes.
... Rather, one "knowledge" has influenced another "knowledge" (e.g., designing machines), in that a product innovation always entails a process innovation, that is the very process of building the product. This process then is enabled and supported by colocated associations, lots of conversations (Ljungberg, 1997;Suchman, 2011), as well as documents and material resources, like sketches, 3D models, material scale models, resource management plans (even workforce schedules), to which this new knowledge can never be totally reduced. ...
In this paper we present an original position on how knowledge is created and shared in organizational domains. We propose a metaphor of diffusion, borrowed from genetics, and a four phase model, which aims to be as simple as the SECI model proposed within the OKCT, but also more comprehensive and sociologically-informed. Our model takes into account the individual, social and cultural dimensions of knowledge (what we denote as co-knowledge) to account for the various ways knowledge is "circulated" among people (i.e., members of any social structure); we also propose ancillary concepts like that of "Knowing Community" and "Knowledge Artifact", as analytical constructs to represent, respectively, the environment hosting such a circulation and the technological driver that either enables or supports it.
... This empirical comparison of the everyday reality of longterm change, in which one general practice developed good quality chronic illness care, confirms the conclusion of Suchman [43] that the dominant discourse of planned, stepwise change in strategically targeted areas of practice activity provides an inaccurate explanation of healthcare improvement. Complex responsive processes of relating, where communicative interaction, power-relating and ideology-based intending, choosing and acting produce patterns of organizing that are paradoxically stable and changing, helps to make sense of the evolution of the practice in ways that were not random, but also not according to a conventional linear blueprint for improvement. ...
Background
Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens.
Methods
This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology.
Results
The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives – re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices.
Conclusions
The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare.
... The PPC-RS may not fully assess all of the organizational, team, or individual provider characteristics that influence these outcomes. For instance, the PPC-RS is not designed or intended to directly evaluate phenomena like team reflexivity that have been shown in health care and other settings to be related to team performance (Gittell et al. 2000;Miller et al. 2001;Stroebel et al. 2005;Gurtner et al. 2007;Suchman 2010). The association of patient communication problems with poor PSUTD and patient experience outcomes in the absence of low PPC-RS domain scores suggests that good performance on the PPC-RS survey is alone not sufficient to produce the desired outcomes, and it underscores the importance of other practice factors not measured by the PPC-RS. ...
Determine, using fuzzy set qualitative comparative analysis (fs/QCA), the relationship between patient-centered medical home (PCMH) systems and quality in 21 NCQA recognized medical homes.
Primary data collected in 2009, including measures of optimal diabetes care (ODC), preventive services up-to-date (PSUTD), patient experience (PEX), survey data assessing PCMH capabilities (PPC-RS), and other clinic characteristics.
Cross-sectional study identifying associations between PPC-RS domains, demographic, socioeconomic, and co-morbidity measures, and quality outcomes.
PPC-RS scores were obtained by surveying clinic leaders. PSUTD and ODC scores were obtained from provider performance data. PEX data were obtained from patient surveys. Demographic, socioeconomic, and co-morbidity data were obtained from EMR and census data.
fs/QCA identified associations between all three outcomes and PCMH capabilities: ODC and team-based care; PSUTD and preventive services systems; and all three outcomes and provider performance reporting systems. Previous statistical analysis of this data had failed to identify these relationships.
fs/QCA identified important associations that were overlooked using conventional statistics in a small-N health services data set. PCMH capabilities are associated with quality outcomes.
Health care delivery organizations are positioned to have a tremendous impact on addressing the variables in the practice environment that contribute to occupational distress and that, when optimized, can promote clinician well-being. Many organizations are committed to this work and have clarity on how to address general, system-wide issues and provide resources for individual clinicians. While such top of the organization elements are essential for success, many of the specific improvement efforts that are necessary must address local challenges at the work unit level (department, division, hospital ward, clinic). Uncertainty of how to address variability and the unique needs of different work units is a barrier to effective action for many health care delivery systems. Overcoming this challenge requires organizations to recognize that unit-specific improvement efforts require a system-level approach. In this manuscript, we outline 7 steps for organizations to consider as they establish the infrastructure to improve professional well-being and provide a description of application and evidence of efficacy from a large academic medical center. Such unit-level efforts to address the unique needs of each specialty and occupation at the work unit level have the ability to address many of the day-to-day issues that drive clinician well-being. An enterprise approach is necessary to systematically advance such unit-level action.
Being a pediatrician presents challenges requiring strength of mind, body, and spirit. In this chapter we explore conceptualizations of emotional resilience and mindset in medicine, with a focus on evidence-informed practices particularly useful for physicians. To aid pediatricians in building their own effective and practical “toolkit” for emotional resilience and mindset, we describe a set of interconnected evidence-based practices whose efficacy has been documented by social scientists and mental health professionals. Building on knowledge from social, cognitive, clinical, and organizational psychology we highlight practices including mindfulness, positive psychology, dynamic mindset, self-compassion, caring connection, and relational leadership. For each concept we offer examples of practical applications in the day-to-day life of pediatricians. Our intention is to offer knowledge and tools to increase your own personal well-being and happiness. Our ultimate goal is to support a shift toward a healthier, more sustainable culture of health in the environments in which we all practice.KeywordsResilienceEmotional resilienceMindfulnessEmotional intelligenceLeadershipPositive psychologySelf-compassionMindsetGrowth mindset
Distraction in health care is best seen as a mismatch between capabilities (of individuals, teams, and organizations) and the nature of the work that they must accomplish. Mindful practice refers to ways of enhancing those capabilities. Focusing attention on what is most important in the workplace can be achieved by enhancing self-awareness within individuals, situation and emotional awareness within teams, and the structure of healthcare organizations. Collectively, these efforts can affect quality of care, human relationships, and sustainability of the healthcare workforce. Individual, team, and organizational change strategies all require development of attentive observation, critical curiosity, beginner’s mind, and presence. I propose ways of optimizing the healthcare work environment through contemplative practices, team training, and organizational redesign to address distractions that emanate from within one’s one mind as well as those coming from the workplace.
Com toda a revolução tecnológica, cultural, social e política, entramos em um novo paradigma de um mundo conectado, globalizado e com novos desafios a serem enfrentados. Teorias e clássicos métodos de intervenção e mudança parecem não serem suficientes neste novo contexto. Especificamente no campo organizacional, estamos passando por momentos de crise e de mudanças. Está se tornando necessário ressignificar o papel das empresas, o papel dos líderes, o papel dos processos burocráticos e o papel dos valores. O presente artigo traz o entendimento da linguagem como construção social, como uma possível ferramenta de mudança da lógica organizacional. Nesse cenário, a linguagem poética se apresenta como um recurso de construção e ressignificação de sentido, promovendo também a possibilidade de reinvenção organizacional.
In the context of technological, cultural, social and political changes, we are experiencing a new paradigm of an interconnected world, globalised and with new challenges to be faced. Traditional theories and methods of intervention and change appear to be not relevant in this context anymore. Specifically, in the organizational field, struggles for a change is happening. It seems to be urgent to reframe the role of the companies, of the leaders, the role of bureaucratic processes as well as the role of value proposition. The present article brings the understanding of language as a social con-struction, as a possible mean of change in the organisational logic. In this scenario, the poetic lan-guage is presented as a resource to construct and to reframe meaning, promoting the possibility of reinventing organizations.
Engaging individual members of clinical teams in practice improvement initiatives is a challenge. In this commentary, we first summarize evidence supporting enhanced practitioner engagement through the creation of a work environment that builds on mutually respectful relationships and valued interdependencies. We then propose a phased, collaborative process that employs practice talk, a term that describes naturally occurring, collegial conversations among members of clinical teams. Planned interactions among team members, facilitated by individuals trained in dialogic techniques, enable health care providers and support staff to share their experiences and expertise, agree on what improvements they would like to make, and test the success of these changes. Participants would be encouraged to express their own suggestions for better practice and disclose strategies that are already working. Dissent would be regarded as an opportunity rather than a barrier. Iterative, sense-making conversations would generate a shared vision, enabling team members to engage in the entire process. Given that practice improvement ultimately depends on frontline providers, we encourage the exploration of innovative engagement strategies that will enable entire clinical teams to develop the collaborative learning skills needed to accomplish their goals.
© 2015 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education.
Dialogue is essential for transforming institutions into learning organizations, yet many well-known characteristics of academic health centers (AHCs) interfere with open discussion. Rigid hierarchies, intense competition for resources, and the power of peer review in advancement processes all hamper difficult conversations, thereby contributing to organizational silence, and at great cost to the institution. Information necessary for critical decisions is not shared, individuals and the organization do not learn from mistakes, and diverse perspectives from those with less power are not entertained, or worse, are suppressed. When leaders become more skilled at inviting multiple perspectives and faculty more adept at broaching difficult conversations with those in power, differences are more effectively addressed and conflicts resolved. In this article, the authors frame why this skill is an essential competency for faculty and leaders alike and provide the following recommendations to institutions for increasing capacity in this area: (1) develop leaders to counteract organizational silence, (2) develop faculty members' skills in raising difficult issues with those in positions of power, and (3) train mentors to coach others in raising difficult conversations. The vitality of AHCs requires that faculty and institutional leaders develop relational communication skills and partner in learning through challenging conversations.
Information is limited regarding the readiness of primary care practices to make the transformational changes necessary to implement the patient-centered medical home (PCMH) model. Using comparative, qualitative data, we provide practical guidelines for assessing and increasing readiness for PCMH implementation.
We used a comparative case study design to assess primary care practices' readiness for PCMH implementation in sixteen practices from twelve different physician organizations in Michigan. Two major components of organizational readiness, motivation and capability, were assessed. We interviewed eight practice teams with higher PCMH scores and eight with lower PCMH scores, along with the leaders of the physician organizations of these practices, yielding sixty-six semistructured interviews.
The respondents from the higher and lower PCMH scoring practices reported different motivations and capabilities for pursuing PCMH. Their motivations pertained to the perceived value of PCMH, financial incentives, understanding of specific PCMH requirements, and overall commitment to change. Capabilities that were discussed included the time demands of implementation, the difficulty of changing patients' behavior, and the challenges of adopting health information technology. Enhancing the implementation of PCMH within practices included taking an incremental approach, using data, building a team and defining roles of its members, and meeting regularly to discuss the implementation. The respondents valued external organizational support, regardless of its source.
The respondents from the higher and lower PCMH scoring practices commented on similar aspects of readiness-motivation and capability-but offered very different views of them. Our findings suggest the importance of understanding practice perceptions of the motivations for PCMH and the capability to undertake change. While this study identified some initial approaches that physician organizations and practices have used to prepare for practice redesign, we need much more information about their effectiveness.
Background
We are sick and tired of being redisorganized.
Objective
To systematically review the empirical evidence for organizational theories and repeated reorganizations.
Methods
We did not find anything worth reading, other than Dilbert, so we fantasized. Unfortunately, our fantasies may well resemble many people's realities. We are sorry about this, but it is not our fault.
Results
We discovered many reasons for repeated reorganizations, the most common being ‘no good reason’. We estimated that trillions of dollars are being spent on strategic and organizational planning activities each year, thus providing lots of good reasons for hundreds of thousands of people, including us, to get into the business. New leaders who are intoxicated with the prospect of change further fuel perpetual cycles of redisorganization. We identified eight indicators of successful redisorganizations, including large consultancy fees paid to friends and relatives.
Conclusions
We propose the establishment of ethics committees to review all future redisorganization proposals in order to put a stop to uncontrolled, unplanned experimentation inflicted on providers and users of the health services.
Be not afraid of life. Believe that life is worth living, and your belief will help you create the fact. —William James. We can easily forgive a child who is afraid of the dark. The real tragedy of life is when men are afraid of the light. —Plato. Modern management thought was born proclaiming that organizations are the triumph of the human imagination. As made and imaged, organizations are products of human imagination. As made and imagined, organizations are products of human interaction and mind rather than some blind expression of an underlying natural order (McGregor, 1960; Berger and Luckmann, 1967; Pfeffer, 1981; Gergen, 1982; Srivastva and Associates, 1983; Schein, 1985; Unger, 1987). Deceptively simple yet so entirely radical in implication, this insight is still shattering many beliefs—one of which is the longstanding conviction that bureaucracy, oligarchy, and other forms of hierarchical domination are inevitable. Today we know that this simply is not true. Recognizing the symbolic and socially constructed nature of the human universe, we now find new legitimacy for the mounting wave of socio-cognitive and socio-cultural research, all of which is converging around one essential and empowering thesis: that there is little about collective action or organization development that is preprogrammed, unilaterally determined, or stimulus bound in any direct physical or material way. Seemingly immutable ideas about people and organizations are being directly challenged and transformed on an unprecedented scale. Indeed, as we move into a postmodern global society we are breaking out of our parochial perspectives and are recognizing that organizations in all societies exist in a wide array of types and species and function within a dynamic spectrum of beliefs and lifestyles. And according to the social constructionist viewpoint, the possibilities are infinite.
This book is about human motivation, and it is organized around the important distinction between whether a behavior is autonomous or controlled.
The aims of this book are simply stated: They are to use a comprehensive body of motivational research to examine the relation between autonomy and responsibility and to reflect on the issue of promoting responsibility in an alienating world.
By examining behaviors that can be properly described as autonomous and exploring the motivational processes through which they are regulated, we have been able to detail both the socio-contextual antecedents of these behaviors and their consequences. [These matters] provide a basis for addressing concrete and practical questions such as how to promote responsible behaviors—like effective work performance, efficient and enjoyable learning, and long-term healthy behavior change—that benefit society as well as its individuals. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The empirical basis of this paper is a two-year project to bring new learning environments and methodologies to rural Thailand. Pilot projects were mounted outside of the education system, with the specific purpose of breaking “educational mind-sets” that have been identified as blocks to educational reform. A salient example of such a mind-set is the assumption that the population and teachers of rural areas lack the cognitive foundations for modern technological education. The work required a flexible approach to the design of digitally based educational interventions. Analysis of design issues led to a theoretical framework, Emergent Design, for investigating how choice of design methodology contributes to the success or failure of education reforms. A practice of “applied epistemological anthropology,” which consists of probing for skills and knowledge resident in a community and using these as bridges to new content, was developed. Analysis of learning behaviors led to the identification of an “engine culture” in rural Thailand as an unrecognized source of “latent learning potential.” This discovery has begun to spawn a theoretical inquiry with significant promise for assessment of the learning potential of developing countries.
The most efficient way to improve health is to use locally available, sustainable, and effective approaches. In the 1970s policy developers tested the concept that public health interventions could be designed around uncommon, beneficial health behaviours that some community members already practised.(1 2) This concept-known as positive deviance(3 4)-was used successfully to improve the nutritional status of children in several settings in the 1990s.(5-10) Recently, the approach has also been applied to newborn care, child nutrition, rates of contraception, safe sexual practices, and educational outcomes.(11-13) In this article we describe how the approach works, the evidence that it is effective, and possible future applications.
To explore in depth how primary care clinicians (general practitioners and practice nurses) derive their individual and collective healthcare decisions.
Ethnographic study using standard methods (non-participant observation, semistructured interviews, and documentary review) over two years to collect data, which were analysed thematically.
Two general practices, one in the south of England and the other in the north of England.
Nine doctors, three nurses, one phlebotomist, and associated medical staff in one practice provided the initial data; the emerging model was checked for transferability with general practitioners in the second practice.
Clinicians rarely accessed and used explicit evidence from research or other sources directly, but relied on "mindlines"--collectively reinforced, internalised, tacit guidelines. These were informed by brief reading but mainly by their own and their colleagues' experience, their interactions with each other and with opinion leaders, patients, and pharmaceutical representatives, and other sources of largely tacit knowledge. Mediated by organisational demands and constraints, mindlines were iteratively negotiated with a variety of key actors, often through a range of informal interactions in fluid "communities of practice," resulting in socially constructed "knowledge in practice."
These findings highlight the potential advantage of exploiting existing formal and informal networking as a key to conveying evidence to clinicians.
This paper presents a novel conceptualization of policy making as social drama. The selection and presentation of evidence for policy making, including the choice of which questions to ask, which evidence to compile in a synthesis and which syntheses to bring to the policy making table, should be considered as moves in a rhetorical argumentation game and not as the harvesting of objective facts to be fed into a logical decision-making sequence. Viewing policy making as argument does not mean it is beyond rationality--merely that we must redefine rationality to include not only logical inference and probabilistic reasoning, but also the consideration of plausibility by a reasonable audience. We need better evidence, but we also urgently need better awareness by policy makers of the language games on which their work depends.
Medical researchers have shown that relationship-centered healthcare increases patient satisfaction and improves health outcomes. The components of relationship-centered healthcare--listening, sharing decision making, and respecting others--improve patient motivation and commitment to a plan of action. Currently, no data are available on the extent to which medical administrative settings adhere to relationship-centered principles. To begin to answer this question, we observed a convenience sample of 45 meetings in healthcare settings to assess the frequency and types of relationship-centered behaviors shown by group leaders. Our results provide preliminary data that leaders, especially female leaders, praised the value of group member efforts and encouraged members to provide input. Less frequently employed relationship-centered behaviors included providing a verbal summary of a discussion, responding to feelings expressed by members, and setting explicit agendas. Finally, we found some provocative associations. Female leaders received higher satisfaction ratings, and male leaders were more verbally dominant. Similar to physician-patient interaction, new topics for discussion are less likely to arise spontaneously late in a meeting if early agenda setting is utilized. To our knowledge, this is the first such study in a medical setting. Our findings encourage those who chair meetings to reflect on the extent to which they use a collaborative approach and offer specific content areas on which to focus. Further research on the concept and outcomes of relationship-centered administrative approach is warranted.
We are sick and tired of being redisorganized.
To systematically review the empirical evidence for organizational theories and repeated reorganizations.
We did not find anything worth reading, other than Dilbert, so we fantasized. Unfortunately, our fantasies may well resemble many people's realities. We are sorry about this, but it is not our fault.
We discovered many reasons for repeated reorganizations, the most common being 'no good reason'. We estimated that trillions of dollars are being spent on strategic and organizational planning activities each year, thus providing lots of good reasons for hundreds of thousands of people, including us, to get into the business. New leaders who are intoxicated with the prospect of change further fuel perpetual cycles of redisorganization. We identified eight indicators of successful redisorganizations, including large consultancy fees paid to friends and relatives.
We propose the establishment of ethics committees to review all future redisorganization proposals in order to put a stop to uncontrolled, unplanned experimentation inflicted providers and users of the health services.
In the early 1890s, Dr William Halsted developed radical mastectomy for breast cancer. Surgeons performed the Halsted procedure for more than 80 years even though there was little systematic evidence for its success. Then a new breed of scholars subjected the procedure to formal methods of evaluation unknown to Halsted.1 The methods—randomized controlled trials (RCTs) principal among them—led to a surprise: radical mastectomy had no advantage over simpler forms of treatment.2
Calls for organizational culture change are audible in many health care discourses today, including those focused on medical education, patient safety, service quality, and translational research. In spite of many efforts, traditional "top-down" approaches to changing culture and relational patterns in organizations often disappoint.
In an effort to better align our informal curriculum with our formal competency-based curriculum, Indiana University School of Medicine (IUSM) initiated a school-wide culture change project using an alternative, participatory approach that built on the interests, strengths, and values of IUSM individuals and microsystems.
Employing a strategy of "emergent design," we began by gathering and presenting stories of IUSM's culture at its best to foster mindfulness of positive relational patterns already present in the IUSM environment. We then tracked and supported new initiatives stimulated by dissemination of the stories.
The vision of a new IUSM culture combined with the initial narrative intervention have prompted significant unanticipated shifts in ordinary activities and behavior, including a redesigned admissions process, new relational practices at faculty meetings, student-initiated publications, and modifications of major administrative projects such as department chair performance reviews and mission-based management. Students' satisfaction with their educational experience rose sharply from historical patterns, and reflective narratives describe significant changes in the work and learning environment.
This case study of emergent change in a medical school's informal curriculum illustrates the efficacy of novel approaches to organizational development. Large-scale change can be promoted with an emergent, non-prescriptive strategy, an appreciative perspective, and focused and sustained attention to everyday relational patterns.
The ongoing significant investment in basic science and clinical discovery in the United States continues to produce impressive results. However, the United States struggles to deliver high-quality care and improved health outcomes due to the systematic failure of discoveries to reach patients in a timely fashion.1- 2 Despite expenditures that reached $2 trillion or more than $6000 per capita in 2005,3 the United States will continue to fail to fully leverage new clinical discoveries into improved health outcomes unless there is an accelerated transformation of the health care system.4 The research enterprise cannot achieve this alone. We propose a model to transform the US health care system (Figure), intended to accelerate the pace at which innovations are implemented in clinical settings by addressing the “how” of health care delivery.
This is not a book about charismatic visionary leaders. It is not about visionary product concepts or visionary products or visionary market insights. Nor is it about just having a corporate vision. This is a book about something far more important, enduring, and substantial. This is a book about visionary companies.' Drawing upon a six-year research project at the Stanford University Graduate School of Business, Collins and Porras took eighteen truly exceptional and long-lasting companies and studied each company in direct comparison to one of its top competitors. They examined the companies from their very beginnings to the present day - as start-ups, as midsize companies and as large corporations. Throughout, the authors asked: 'What makes the truly exceptional companies different from other companies?' Filled with hundreds of specific examples and organized into a coherent framework of practical concepts that can be applied by managers and entrepreneurs at all levels, Built to Last provides a master blueprint for building organizations that will prosper long into the twenty-first century and beyond.
This article describes the deficiencies of positivist science for generating knowledge for use in solving problems that members of organizations face. Action research is introduced as a method for correcting these deficiencies. When action research is tested against the criteria of positivist science, action research is found not to meet its critical tests. The appropriateness of positivist science is questioned as a basis for judging the scientific merits of action research. Action research can base its legitimacy as science in philosophical traditions that are different from those which legitimate positivist science. Criteria and methods of science appropriate to action research are offered.
By showing how cognitive, normative, and cultural phenomena are linked to the neurophysiology underlying attachment and social interaction, the authors point in the direction of further modeling the deep biological foundations of social behavior. Hopfield networks provide useful computational frameworks for studying cognitive prototypes. The authors show that Hopfield networks can be useful in studying how behavior and cognition work in tandem, within the context of social interaction, to regulate activity in core brain systems—in effect, controlling comfort and modulating arousal.
Topics discussed are: affect regulation; behavioral mechanisms of opioid and arousal regulation; social mechanisms of opioid and arousal regulation; cognitive mechanisms of opioid and arousal regulation; Hopfield networks; a Hopfield network model of arousal modulation; transference and the generalization of attachment; resistance of working models to change later in life; inconsistent, incoherent, or fragmented working models; cognitive dissonance and balance theory; dependency, prototype building and interaction pressures; joint reconstruction of cognitive structures; interaction ritual and normativity; intimacy, talk, transitional objects, and symbolism; and culture and comfort. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Major difficulties arise when introducing evidence and clinical guidelines into routine daily practice. Data show that many patients do not receive appropriate care, or receive unnecessary or harmful care. Many approaches claim to offer solutions to this problem; which ones are as yet the most effective and efficient is unclear. We aim to provide an overview of present knowledge about initiatives to changing medical practice. Substantial evidence suggests that to change behaviour is possible, but this change generally requires comprehensive approaches at different levels (doctor, team practice, hospital, wider environment), tailored to specific settings and target groups. Plans for change should be based on characteristics of the evidence or guideline itself and barriers and facilitators to change. In general, evidence shows that none of the approaches for transferring evidence to practice is superior to all changes in all situations.
Research strategies which emphasize participation are increasingly used in health research. Breaking the linear mould of conventional research, participatory research focuses on a process of sequential reflection and action, carried out with and by local people rather than on them. Local knowledge and perspectives are not only acknowledged but form the basis for research and planning. Many of the methods used in participatory research are drawn from mainstream disciplines and conventional research itself involves varying degrees of participation. The key difference between participatory and conventional methodologies lies in the location of power in the research process. We review some of the participatory methodologies which are currently being popularized in health research, focusing on the issue of control over the research process. Participatory research raises personal, professional and political challenges which go beyond the bounds of the production of information. Problematizing 'participation', we explore the challenges and dilemmas of participatory practice.
The authors raise questions regarding the wide-spread calls emanating from lay and medical audiences alike to intensify the formal teaching of ethics within the medical school curriculum. In particular, they challenge a prevailing belief within the culture of medicine that while it may be possible to teach information about ethics (e.g., skills in recognizing the presence of common ethical problems, skills in ethical reasoning, or improved understanding of the language and concepts of ethics), course material or even an entire curriculum can in no way decisively influence a student's personality or ensure ethical conduct. To this end, several issues are explored, including whether medical ethics is best framed as a body of knowledge and skills or as part of one's professional identity. The authors argue that most of the critical determinants of physician identity operate not within the formal curriculum but in a more subtle, less officially recognized "hidden curriculum." The overall process of medical education is presented as a form of moral training of which formal instruction in ethics constitutes only one small piece. Finally, the authors maintain that any attempt to develop a comprehensive ethics curriculum must acknowledge the broader cultural milieu within which that curriculum must function. In conclusion, they offer recommendations on how an ethics curriculum might be more fruitfully structured to become a seamless part of the training process.
The rapidly changing organizational context within which health care is delivered is altering provider-patient relations and processes of clinical decision-making, with significant implications for patient outcomes. Yet definitive research on such effects is lacking. The authors seek to underscore the contribution of organizational research to studies of clinical outcomes and demonstrates several approaches to further such efforts.
The authors present a theoretical framework of the operant mechanisms linking organizational attributes and patient outcomes. They use case examples from their ongoing research on hospitals to illustrate strategies for measuring these mechanisms and for overcoming some of the feasibility issues inherent in organizational research.
Several methodological issues are explored: (1) exploiting "targets of opportunity" and "natural experiments" is a promising strategy for studying patient outcomes related to organizational reform; (2) indices of organizational traits, constructed from individual survey responses, can illuminate the operant mechanisms by which structure affects outcomes; and (3) secondary data sources and innovative statistical matching procedures provide a feasible strategy for constructing study comparison groups. Extending the organizational outcomes research strategy to new areas of inquiry offers an opportunity to enhance our understanding of how nursing organization affects outcomes.
Improving the effectiveness of medical care in a health-care system undergoing fundamental restructuring requires greater understanding of how organizational context affects clinical outcomes. A higher priority should be placed on organizational outcomes research by researchers and funding agencies.
Health care organizations face pressures from patients to improve the quality of care and clinical outcomes, as well as pressures from managed care to do so more efficiently. Coordination, the management of task interdependencies, is one way that health care organizations have attempted to meet these conflicting demands.
The objectives of this study were to introduce the concept of relational coordination and to determine its impact on the quality of care, postoperative pain and functioning, and the length of stay for patients undergoing an elective surgical procedure. Relational coordination comprises frequent, timely, accurate communication, as well as problem-solving, shared goals, shared knowledge, and mutual respect among health care providers.
Relational coordination was measured by a cross-sectional questionnaire of health care providers. Quality of care was measured by a cross-sectional postoperative questionnaire of total hip and knee arthroplasty patients. On the same questionnaire, postoperative pain and functioning were measured by the WOMAC osteoarthritis instrument. Length of stay was measured from individual patient hospital records.
The subjects for this study were 338 care providers and 878 patients who completed questionnaires from 9 hospitals in Boston, MA, New York, NY, and Dallas, TX, between July and December 1997.
Quality of care, postoperative pain and functioning, and length of acute hospital stay.
Relational coordination varied significantly between sites, ranging from 3.86 to 4.22 (P <0.001). Quality of care was significantly improved by relational coordination (P <0.001) and each of its dimensions. Postoperative pain was significantly reduced by relational coordination (P = 0.041), whereas postoperative functioning was significantly improved by several dimensions of relational coordination, including the frequency of communication (P = 0.044), the strength of shared goals (P = 0.035), and the degree of mutual respect (P = 0.030) among care providers. Length of stay was significantly shortened (53.77%, P <0.001) by relational coordination and each of its dimensions.
Relational coordination across health care providers is associated with improved quality of care, reduced postoperative pain, and decreased lengths of hospital stay for patients undergoing total joint arthroplasty. These findings support the design of formal practices to strengthen communication and relationships among key caregivers on surgical units.
Complexity originates from the tendency of large dynamical systems to organize themselves into a critical state, with avalanches or "punctuations" of all sizes. In the critical state, events which would otherwise be uncoupled become correlated. The apparent, historical contingency in many sciences, including geology, biology, and economics, finds a natural interpretation as a self-organized critical phenomenon. These ideas are discussed in the context of simple mathematical models of sandpiles and biological evolution. Insights are gained not only from numerical simulations but also from rigorous mathematical analysis.
The social environment or "informal" curriculum of a medical school profoundly influences students' values and professional identities. The Indiana University School of Medicine is seeking to foster a social environment that consistently embodies and reinforces the values of its formal competency-based curriculum. Using an appreciative narrative-based approach, we have been encouraging students, residents, and faculty to be more mindful of relationship dynamics throughout the school. As participants discover how much relational capacity already exists and how widespread is the desire for a more collaborative environment, their perceptions of the school seem to shift, evoking behavior change and hopeful expectations for the future.
Physicians are immersed in stories. They hear stories from patients, tell them to other physicians, and recall them in quiet moments.1 Literary scholars, folklorists, and historians have long emphasized the importance of stories.2,3 In recent years, physicians trained in these disciplines have considered the role of stories in clinical practice. The physician-anthropologist Kleinman suggests that physicians need to move beyond “clinical interrogation” to listen attentively to their patients’ narratives of illness.4(p9),5 Charon draws on her background in literary studies to suggest that the practice of medicine requires “narrative competence,” which she defines as “the set of skills required to recognize, absorb, interpret, and be moved by the stories one hears or reads.”6(p862) She further proposes that physicians can enhance their clinical and emotional development through retelling clinical stories.
Four domains of relationship have been highlighted as the cornerstones of relationship-centered health care. Of these, clinician-patient relationships have been most thoroughly studied, with a rich empirical literature illuminating significant linkages between clinician-patient relationship quality and a wide range of outcomes. This paper explores the realm of clinician-colleague relationships, which we define to include the full array of relationships among clinicians, staff, and administrators in health care organizations. Building on a stream of relevant theories and empirical literature that have emerged over the past decade, we synthesize available evidence on the role of organizational culture and relationships in shaping outcomes, and posit a model of relationship-centered organizations. We conclude that turning attention to relationship-centered theory and practice in health care holds promise for advancing care to a new level, with breakthroughs in quality of care, quality of life for those who provide it, and organizational performance.
Relationship-centered care (RCC) is a clinical philosophy that stresses partnership, careful attention to relational process, shared decision-making, and self-awareness. A new complexity-inspired theory of human interaction called complex responsive processes of relating (CRPR) offers strong theoretical confirmation for the principles and practices of RCC, and thus may be of interest to communications researchers and reflective practitioners. It points out the nonlinear nature of human interaction and accounts for the emergence of self-organizing patterns of meaning (e.g., themes or ideas) and patterns of relating (e.g., power relations). CRPR offers fresh new perspectives on the mind, self, communication, and organizations. For observers of interaction, it focuses attention on the nature of moment-to-moment relational process, the value of difference and diversity, and the importance of authentic and responsive participation, thus closely corresponding to and providing theoretical support for RCC.
This paper explores and contrasts personal philosophies based on two different core values, control and relation, with respect to expectations, social relationships, habits of perception and interpretation, and ways of feeling grounded in the world. The paradigm of control is widespread in medicine and certain other health professions, but because it fosters unrealistic expectations, evokes fear and shame, and inhibits effective partnerships, it can actually compromise health outcomes. The paradigm of relation calls attention to interpersonal process and fosters receptivity and adaptability, thus enhancing partnership. A mature clinical approach combines these two perspectives, respecting both the benefits and limitations of reductionistic science and making room for self-organization and emergence.
Research reveals that writing about one's experiences offers an individual the opportunity to improve function, develop insight, and foster growth. Storytelling and story writing are pedagogical tools used frequently in practice professions. It is reasonable to see these writings as a rich source for research. They are vehicles for understanding human experience and aesthetic knowing. This article presents an innovation in the method used for analysis of stories. It is a blending of two established methods, those of narrative analysis as described by Riessman (1993), and aesthetic criticism by Chinn, Maeve, and Bostick (1997). The merging of both methods, termed narrative criticism, allows for a rich level of insight into unique human experiences.
There is growing recognition in the medical community that being a good doctor requires more than strong scientific knowledge and excellent clinical skills. Many key qualities are essential to providing comprehensive care, including the abilities to communicate effectively with patients and colleagues, act in a professional manner, cultivate an awareness of one's own values and prejudices, and provide care with an understanding of the cultural and spiritual dimensions of patients' lives. To ensure that Indiana University School of Medicine (IUSM) graduates demonstrate this range of abilities, IUSM has undertaken a substantial transformation of both its formal curriculum and learning environment (informal curriculum). The authors provide an overview of IUSM's two-part initiative to develop and implement a competency-based formal curriculum that requires students to demonstrate proficiency in nine core competencies and to create simultaneously an informal curriculum that models and supports the moral, professional, and humane values expressed in the formal curriculum. The authors describe the institutional and curricular transformations that have enabled and furthered the new IUSM curricular goals: changes in education administration; education implementation, assessment, and curricular design; admissions procedures; performance tracking; and the development of an electronic infrastructure to facilitate the expanded curriculum. The authors address the cost of reform and the results of two progress reviews. Specific case examples illustrate the interweaving of the formal competency curriculum through the students' four years of training, as well as techniques that are being used to positively influence the IUSM informal curriculum.
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Edward Lorenz, father of chaos theory and butterfly effect, dies at 90. MIT News
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