Relationships in healthcare are complicated. There are competing demands on one’s time and attention, and there are always things not going per plan. There are power gradients and a diversity of personalities and cultural backgrounds and communication styles. If healthcare personnel are not trained in a standardized manner, haven’t had a chance to practice skills in a team setting, or don’t know each other’s respective roles, you can imagine what might happen.
As part of our system-wide initiative to reduce healthcare-associated infections and sepsis mortality, one of our strategies was to improve the way we cared for catheters- both central venous catheters and urinary catheters. We implemented standardized education and periodic audits on how well we took care of catheters for hospitalized patients. Because each patient could potentially come in contact with one to few dozens of healthcare personnel during their hospital stay, we were curious about relationships between nurses and their assistants and other types of healthcare personnel like attending physicians, residents and fellows, respiratory therapists, radiology technicians, and phlebotomists. One tool that stood out for us to use was the relational coordination survey tool that showed associations between the survey scores and performance outcomes in previous studies conducted in healthcare and business settings like the airline industry.
Jodi Gittell and her colleagues found in their research that there are seven aspects of relationships between team members that predicted positive outcomes. They discuss their research on their website http://www.rcrc.brandeis.edu/ Their original research was in the airline industry, and they showed that a relational coordination score which is an aggregate of scores on 1) timeliness, (2) accuracy, (3) frequency, and (4) problem-solving nature of communication; and (5) respect, (6) goals, and (7) knowledge shared with team members strongly predicted fewer passenger complaints, fewer late arrivals and fewer baggage handling errors. They repeated their work in different settings like knee replacement surgery and found that the results are reproducible. On a scale of 1 to 5, an RC score above 4 suggests excellent coordination, an RC score between 3.5 and 4 suggests that the coordination is intermediate and could use improvement, and an RC score less than 3.5 suggests that the relationships are not coordinated enough. Anthony Suchman who has done a lot of work on relationship-centered care cautions that interventions using relational coordination need to be done carefully so as to not invoke negative responses like defensiveness, denial, embarrassment or shame.
Our study was recently published in Infection Control and Hospital Epidemiology journal. Robert Connally was one of our brilliant medical students and a mentee who was very interested in this topic and set up the survey tool and administered the survey and wrote the first draft of the paper. Sylvia Trevino was infection prevention director during those days who helped stratify the clinical areas. Donna Richardson was the senior nurse leader who blessed the study, and Judy Herrington and Jackie Brock were the nursing vice presidents who allowed the nurses to participate. Robert Hendler was the chief quality officer who had added relational coordination to the Parkland vocabulary. We categorized our clinical areas in the hospital into high performing areas and low performing areas, and measured relational coordination scores in each. The specific survey tool is described in the paper. We found that there was no significant difference between scores in high performing units vs. low performing units. We also found that the scores in most units were low. It could be that we need a better tool to assess relationships. It could be that the relationships did need better coordination. It would be interesting to repeat the survey now because the published study was done over three years ago. It could be that this way of assessing relationships works for airline industry outcomes or knee surgery outcomes, but not for catheter care outcomes. In spite of the limitations, doing this study helped us raise awareness about the importance of relationships that are well coordinated. We need to do more research on relationships in health care and how to make them more productive.