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Healthcare is inherently chaotic. Patients are heterogeneous, so their medical problems are complex and their needs variable. Because of this chaos, clinicians need frameworks and the discipline to use them. Yes, every patient is different, and every interaction unique, but structured approaches to interactions with patients enable clinicians to deliver better care and feel calmer while doing so. Clinicians can focus on connecting with the patient, rather than wondering what they should be doing.

This book describes such a framework, along with powerful insights on how to implement it. Adrienne Boissy and her colleagues at Cleveland Clinic have driven remarkable improvements in the communication skills of caregivers, and they have also provided a superb example of how to build social capital. Although this term is not widely used in healthcare today, it is increasingly relevant as we enter a marketplace driven by competition on value—meeting patients’ needs as efficiently as possible. If financial capital refers to the monetary resources that enable organizations to build buildings and accomplish other goals that otherwise would be impossible, social capital describes how relationships within the organization allow it do things it otherwise could not do. Social capital explains how some organizations do a better job at meeting patients’ needs and why others fall short even though their personnel are just as hardworking and well trained. In higher-performing organizations, the whole is greater than the sum of its parts; in weaker organizations, the opposite is often the case.

To increase value, clinicians have to work more effectively with each other, and with patients and their families. To do that, organizations have to be able to increase their social capital. University of Chicago sociologist Ronald S. Burt1 describes two basic ways to do this: brokerage and closure. Brokerage describes how organizations learn, and actually increase the variation in how they do things. Closure describes how they reduce variation, and achieve consistency in working together in an effective and efficient way.

Organizations need both types of functions, as demonstrated by the work on healthcare communication skills at Cleveland Clinic. The Clinic was wise enough to give the responsibility and a blank slate to Boissy, who was well respected by her colleagues but honest and humble enough to admit that she did not know how to accomplish the goal, so she looked outside of her usual context and enlisted other colleagues with the same openness. They spent a year developing an inventory of what work was going on internally, at other healthcare organizations, and at organizations outside healthcare delivery.

In this brokerage phase, Boissy and her colleagues understood that their work was to learn from others, not start from scratch. To learn, and successfully bring ideas from outside into an organization, information brokers have to create what Burt calls “bridges” over which information can traverse, and “holes” through which the information and new practices can enter. Within any large and complex organization, there are suborganizations, and creating bridges and holes among them is an important function of the learning process.

Organizations that are too inwardly focused are at high risk for missing out on new and better ideas that have developed elsewhere. The temptation is always great in any large and well-regarded organization such as Cleveland Clinic to discount work done elsewhere. Fortunately, the Clinic’s leadership was willing to confront data suggesting weak performance and then create the imperative to learn and to improve.

But just learning (idea brokering) is not enough to realize actual improvement; organizations also need “closure,” to make the better ways of doing things the new local norm. Here again, Boissy and her team sensed that clinicians need a structured framework for approaching interactions with patients, and that this framework could only be spread via trusted colleagues.

One of my favorite parts of this book is the description by Dr. Edward Benzel, then chair of Neurosurgery, of his initial reaction to the request that he become a trained facilitator for the communications initiative. Benzel’s response was to try to get the work assigned to a young woman who had recently been recruited to the neurosurgery group. Boissy and her colleagues knew that the framework they were advancing would spread much faster if well-known and trusted authority figures were pushing it. Benzel relented, as did many of his more senior colleagues, and the Clinic avoided one of the most common mistakes in dissemination of best practices—which is to take the path of least resistance and focus efforts on clinicians who have less influence on their colleagues.

When it comes to making a new and better way of doing things a social norm, the accumulation of social capital blurs into social network science. Here, organizations may benefit from the work of researchers such as Yale’s Nicholas Christakis, author of Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives.2 They have shown how values (e.g., good communication being essential to professional excellence) can spread from person to person to person. Financial incentives can capture clinicians’ attention briefly, but to achieve real and sustained improvement, social norms must be strong enough to exert peer pressure upon clinicians to be reliably excellent with every single patient.

It is worth noting that the Cleveland Clinic experience demonstrates that brokerage and closure are not two sequential phases. Both must go on continuously and indefinitely. The Clinic has been modifying its program right from the start, and we can expect it to have evolved a year or two from now. The learning will never stop, nor should the work to achieve closure by standardizing best practices.

Thomas H. Lee, MD, MSc
Chief Medical Officer, Press Ganey
Professor of Medicine (part-time), Harvard Medical School
Professor of Health Policy and Management, Harvard School of Public Health


Ronald S. Burt, Brokerage and Closure: An Introduction to Social Capital (Oxford: Oxford University Press, 2005).


Nicholas A. Christakis and James H. Fowler, Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives (New York: Little, Brown, and Company, 2009).

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