Relational interventions for organizational learning: An experience report

Abstract Introduction Quality improvement and implementation science practitioners identify relational issues as important obstacles to success. Relational interventions may be important for successful performance improvement and fostering Learning Health Systems. Methods This case report describes the experience and lessons learned from implementing a relational approach to organizational change, informed by Relational Coordination Theory, in a health system. Structured interviews were used to obtain qualitative participant feedback. Relational Coordination was measured serially using a validated seven‐item survey. Results An initial, relational intervention on one unit promoted increased participant engagement, self‐efficacy, and motivation that led to the spontaneous, emergent dissemination of relational change, and learning into other parts of the health system. Staff involved in the intervention reported increased systems thinking, enhanced focus on communication and relationships as key drivers for improvement and learning, and greater awareness of organizational change as something co‐created by staff and executives. Conclusions This experience supports the hypothesis that relational interventions are important for fostering the development of Learning Health Systems.


| INTRODUCTION
Quality improvement practitioners report a low overall success rate for their projects, a trend supported by the literature from the past 20 years. [1][2][3][4] These same practitioners identify relational rather than technical issues as the principal obstacles and report that their current tools and approaches do not adequately prepare them for these relational challenges. 1,5 Implementation science practitioners also identify relational factors as key contributors to successful innovation 6,7 ; and workforce engagement and knowledge sharing have been identified as critical elements of learning organizations. 8 The literature on Learning Health Systems is focused on several key themes, especially the technical infrastructure (electronic health records and the like) required to acquire, store, and analyze clinical data and to produce new knowledge for improving clinical performance. 9 In contrast, the social infrastructure of Learning Health Systems does not appear to have received as much attention, 10 despite the fact that most health care is delivered by interprofessional teams and networks of collaborating providers. Information and knowledge flow between individuals and teams via a social network. Social networks strongly influence organizational performance, and are likely to be another important domain for study and intervention in Learning Health Systems (LHSs). 11 New approaches to addressing the relational dimensions of process improvement are needed to accelerate the development of LHSs.
Relational Coordination Theory (RC) is an approach to exploring team collaboration and performance that shares key concepts with complexity science. RC describes seven dimensions of interaction that allow collaborating individuals, workgroups, and/or organizations to coordinate their work and actively manage the interdependencies of their tasks. 12 Four dimensions describe characteristics of communication: frequency, timeliness, accuracy, and when a problem arises, a focus on solving the problem rather than assigning or deflecting blame. The other three dimensions are qualities of relationship: shared goals for the work process, shared knowledge of each other's work, and mutual respect for each other's work (Gittell 2006) 13 RC can be measured by a validated survey, with the resulting score indicating the strength of the network of ties among the collaborating workgroups. 14,15 Extensive research shows that higher levels of RC are consistently associated with higher levels of performance, including clinical outcomes, safety, cost, patient experience, staff satisfaction and wellbeing, and the capacity to innovate (e.g., 14,[16][17][18][19][20][21][22][23][24][25][26][27].
This experience report describes one of the first applications of Relational Coordination Theory as a framework for process improvement, organizational learning, and change management. RC focuses on improving communication, relationships, alignment, and systems awareness to foster more effective collaboration on interdependent tasks, ultimately resulting in performance improvement. We found that a single, relatively simple intervention on one unit promoted a high degree of engagement, learning, improved self-efficacy, and motivation among the participants that led to an unexpected, emergent cascade of dissemination across the health system.

| Organizational context
This project was conducted in a regional healthcare system, anchored by a multi-specialty group practice, a tertiary care hospital, and a network of critical access hospitals. The system, which serves a rural population in a sparsely populated part of the United States, is physician-led and recognized for its culture of innovation and commitment to learning. 28 Clinical departments are led by physician-manager dyads. Novel improvement methods and cultural change frameworks are routinely tried and evaluated. A well-developed Operational Excellence department focuses on operational efficiencies using methods from lean and Six Sigma. In addition, organizational leaders and staff, including the Chief Medical Officer (CMO) and the Director of the Partnership for Complex Systems and Healthcare Innovation (partnership director) participated in a self-study group focused on using complexity science and related change processes, such as RC and positive deviance, in healthcare. Systems science is an essential and distinguishing attribute of LHS research identified by the Agency for Healthcare Research and Quality. 29 Complexity science, as applied to organizations, focuses attention on the emergent, self-organizing nature of human interaction, and calls for a leadership approach that emphasizes process reflection, relational quality, and co-creation, with less emphasis on command and control strategies. 30 Intrigued by the RC approach to system-ness and collaboration, the complexity study group began searching for an opportunity to trial an improvement project informed by RC. The project began in 2012 and is ongoing. We report interim results as of 2017.
The first opportunity to apply RC was the relocation of the intensive care unit (ICU). The ICU staff was anticipating a move to a new facility that featured a physical footprint almost three times larger than the old one and multiple nursing pods rather than one large central workspace. The staff was concerned that the spatial separation would negatively impact their ability to communicate and collaborate, and thus, the quality of patient care.

| The RC intervention
The RC intervention was implemented iteratively in successive waves, introducing the concepts of interdependence and RC, measuring the RC between various workgroups, discussing the results and lessons learned, and taking action based on the findings. Because of the iterative learning nature of the intervention, we report RC survey results in the Methods section.
The first step involved outreach and engagement on the part of the CMO and the Partnership Director. They circulated articles about RC to the ICU staff and attended meetings of various groups (eg, the ICU nursing partnership council, department of pulmonary-critical care medicine, and the rehabilitation department) to present an overview of RC and to ask whether it made sense to these groups to employ RC as a framework to enhance collaboration in the face of the impending move. The response from front-line staff, pulmonarycritical care physicians, and ICU leadership was widespread agreement. The ICU staff was known for valuing collaboration and a willingness to try innovative improvement approaches.
During these various meetings and related informal conversations, the CMO and the Partnership Director identified staff members who seemed particularly enthusiastic about this approach and invited them to join an interprofessional project team to plan and lead the effort.
Many of them possessed an existing interest in multidisciplinary collaboration. The initial project team included two occupational therapists, two intensivists, the ICU case manager, a physical therapist, nurse, critical care pharmacist, ICU clinical coordinator, speech therapist, and respiratory therapist. The case manager, one of the occupational therapists, and the clinical coordinator emerged as leaders by stepping forward to communicate actively with ICU colleagues, build interest, and pilot changes.
The CMO and the Partnership Director liaised with system leadership and provided consultative support on implementation science, staff engagement strategies, and relational coordination. The CMO was also an actively practicing pulmonary-critical care physician.
He thus brought first-hand knowledge about ICU operations and direct senior leadership support for the project.
The project team, which named itself "ICU Connections", then  Responding to patterns revealed by the survey, the project team created two initial interventions -a newsletter and RC Bingo -to help the various workgroups in the ICU better understand and thus be more responsive to each other's work. The latter was a game in which staff members nominated peers from professions other than their own whose actions supported relational coordination (see Figure 2).
Nominations were posted on a Bingo Board with workgroups on one axis and the RC dimensions on the other. The first profession to receive nominations on all seven RC dimensions was awarded a pizza party.
Motivated by their workgroup's initial low score of 3.33 on the RC survey, the occupational and physical therapists on the project team initiated two activities to improve working relationships with their ICU colleagues. They started contacting nurses each morning to F I G U R E 1 Results of the baseline Relational Coordination surveys showing ratings of the ICU staff by ICU staff members, including physicians, and by patients and family members. On a scale of 1 to 5 less than 3.5 is considered weak performance (orange bars), 3.5 to 4 moderate performance (blue bars), greater than 4 strong performance (green bars) discuss their patients' care plans, particularly their needs for therapy, and the optimal timing for therapy. They also conducted a chart review to determine what they could have added to the care of ICU patients for whom they had not been consulted. They shared the findings of the chart review and care plan ideas with ICU physicians and nurses and on daily rounds to increase the staff's knowledge of the capabilities and potential impact of the therapists. In the year following these activities, the proportion of ICU patients receiving OT and PT therapy rose from 28% to 70%.

| RESULTS
Qualitative analysis of the interview transcripts yielded four major themes, illustrated with some exemplar quotations from the survey.

| RC changes how people think about their work
It fosters systems thinking, helping people understand their own work in the context of the larger whole. It helps staff pay more attention to who else is involved in their work processes, to value multiple perspectives, and to heighten awareness of interconnections and interdependencies.
It's been eye opening -how many people depend on each other to get things done… I no longer take for granted the work of others and am careful about making assumptions about what they do and why they do it. (Case manager).
The whole foundation of the interdisciplinary team does not just exist at the bedside, but at the leadership level and between units and departments. RC has helped me appreciate this and focus more on relationships and less on personalities. (Unit manager).

| RC promotes inclusiveness and improves collaboration
It increases relationship-building, communication, and shared decision-making, and decreases blaming. It encourages people to engage with and value the input of all participants in a work process.
Before my exposure to RC I thought all aspects of care should be driven by nursing. Now I see it's a team process. As a consequence, I'm much more inclusive now. (ICU nurse).
The comfort level of professionals from different disciplines in the ICU with raising concerns, making suggestions, and solving problems together has increased dramatically. (Nursing director).

| RC promotes personal development and fulfillment
The new perspectives, behavior changes, improved relationships, and improved performance associated with RC increased people's sense of self-efficacy and confidence. RC fostered learning and increased the joy, meaning, and pride that people experience in their work.
The experience in the ICU made me feel part of something important and helped me realize I can make contributions to the organization. Interviews also identified two challenges staff experienced with the RC intervention. First, the novelty of RC induced initial skepticism from some colleagues, and there was discomfort with the terminology of RC, which some perceived as jargon. The project team accommodated this discomfort by using the term ICU Connections, rather than mentioning RC specifically. Subsequently, with familiarity, the language of RC became widely used throughout the organization. Secondly, the project team encountered minor, temporary resistance to some of their interventions, particularly family rounding, which was overcome by allowing physicians to choose whether to participate.
Eventually, all chose to participate.

| DISCUSSION
In contrast to most improvement efforts where a large effort often produces little or no benefit, we were struck that one modest RCbased intervention to address one concern in one unit could lead to a cascade of initiative, engagement, and learning across many parts of the organization. This relationally focused intervention not only succeeded at its original tactical goal of maintaining cohesiveness among the ICU staff as they relocated to larger decentralized quarters, but also initiated a cascade of other process improvements in the ICU and elsewhere.
Qualitative feedback from survey participants indicates the RC intervention fostered learning at a number of levels in the organization. Staff learned to see their workplace more systemically; they acquired a more accurate and complete understanding of the work of their co-workers; and they learned to value that work more highly.
The RC intervention manifested several characteristics we associate with learning activities. First, participating staff acquired new perceptions, facts, and understanding, as listed above. Second, the spontane- • The RC approach emphasizes co-creation. This helped the executives resist the temptation to impose a top-down solution and instead engage the ICU staff as co-designers of the intervention.
They did introduce the first intervention, the RC survey, but only with the awareness and agreement of the ICU staff; after that the grass roots project team created every subsequent intervention. In accord with Self-Determination Theory, a theory of intrinsic motivation and behavior change, this support for the staff members' autonomy enhanced their engagement, motivation and commitment, and learning as demonstrated in the interviews. 31 Interventions like the one we have described are complex, and the success of such interventions is dependent on context, proper matching of the intervention to the "problem", and expertise in execution. This RC-informed initiative took place in an organizational setting characterized by pre-existing familiarity and engagement with complexity science concepts, and strong leadership support for the application of these concepts for learning and improvement. While little is known about the configurations of conditions associated with success or failure of RC-informed interventions, it seems plausible that the characteristics of the organization played an important role in enabling the outcomes we observed.

| CONCLUSION
In summary, we have described our experience applying a relational approach to process improvement based on Relational Coordination Theory. This approach allowed the staff of an ICU to see for