Healthcare is Ultimately a Social Enterprise: Building better systems through "Relational Coordination"

Have you ever thought of an x-ray technologist as a key player in promoting high-value, cost-conscious care?

This week an x-ray tech saved one of my patients from unnecessary imaging.  Here is the story: last fall we had set up a 6 month follow-up ultrasound to check on a patient’s abdominal aortic aneurysm, an aneurysm that was too small to require surgery, but too large to ignore. The day before the ultrasound the tech called and asked if we still wanted the test, as an abdomen CT had just been done by another physician for a different reason. Since a CT is as good or better at looking at the aorta, we didn’t need the ultrasound. Test cancelled. Patient saved another trip and co-pay. Overall spending reduced. Good call on the technician’s part.

The next day we received a call on a different patient, this time the tech asking if we wanted to add a CT of the neck to the CT chest we had ordered. She had listened to my dictation and heard about swelling in the neck and thought we could save the patient a second trip if we added cuts through the neck as well as the chest. It was a good idea.

So what is going on? It turns out that at the direction of their departmental manager, Tina Stillmunkes, the x-ray technicians have begun reviewing the clinical scenario of each patient on the next day’s schedule, the radiology equivalent of the “visit-prep” my nurses do for each of our clinic patients. The technician reviews the indication for the test, any previous related imaging and the relevant laboratory studies, and obtains outside images if need be. If anything seems out of line or questionable, s/he brings it to the radiologist’s attention, and then calls the nurse on the clinical team.

This way we take better care of our patients and we order tests more appropriately. The radiologists and the x-ray technicians are the experts in their field, and their functioning as thoughtful professionals as opposed to just carrying out orders, has improved the care in our organization. And it could decrease overall healthcare spending as unneeded tests are caught before they are performed.

It is a sign of professionalism: Our x-ray department now staffs 3 CT technicians, rather than the previous 2, with one technician assigned to “chart prep.”  This extra staff time could result in less revenue to the department, as some studies are cancelled. But it also results in more appropriate testing and fewer delays in diagnosis.

How did this happen? It took staffing changes (increased staffing to cover the new duties), technology changes (computer stations with speakers so the techs could listen to any dictation that had not yet been transcribed) and cultural changes (the techs had to feel comfortable approaching the radiologists and the radiologists had to be committed to educating the techs.)

What does this show? To me it shows the power of human relationships. Healthcare is ultimately a social enterprise. We can reduce it down to a series of electronic steps and lose the humanity. Or we can leverage the professionalism among the people who come to work every day. When the oncology nurse talks with the family medicine nurse care is more tightly woven together for patients and families.  When the surgeon talks with the pulmonologist errors are less likely. When the internist talks with the pharmacist medication choices are optimized.

It shows the power of “relational coordination” a term coined by Jody Hoffer-Gittel.  The core concept of relational coordination, originating in the airline industry, is that highly functional work environments require strong conduits for communication, as well as respect and relationship between different roles within the organization. In healthcare there is a linear correlation between the degree of relational coordination within an organization and the outcomes the organization achieves. Higher relational coordination--the more likely workers of different roles are to greet each other, respect each other or speak to each other--the better the outcomes. The more likely gate agents are to greet the pilots, the more likely the planes will run on time. The more comfortable surgeons are speaking with circulating nurses the better the operation room outcomes.

Similarly, in my view, when an x-ray technician is encouraged to learn, think and question, and is empowered to approach the radiologist and then the clinical team, the care is better.

Relational coordination depends on participants having a high degree of shared knowledge regarding each other's tasks and on having shared goals.  In an organization with strong relational coordination pharmacists know the role of a nurse and have no barriers to communicating. Nurses understand the responsibilities and share the goals of safe, efficient patient care with radiology technicians. Laboratory personnel feel respected and able to communicate with physicians. Gittell relates, “When participants know how their tasks fit together with the tasks of others in the same work process, they have a context for knowing who will be impacted by any given change and therefore for knowing who needs to know what, and with what urgency.”

The solution to our healthcare costs and quality is not always electronic, it will not always come from a new technology-imposed constraint or policy mandate, operationalized through a series of hard-stops and drop down boxes. In many, often better ways, I believe, quality will be greater and costs lower when individuals work within a system that supports agency, connection and a professional commitment to the needs of patients. It really is all about culture, and you can’t command culture through rigid decision support and mandated physician order entry. But you can support and nurture culture with good processes, communication and leadership. Hats off to Tina Stillmunkes for showing us how this can be done!