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This book explores how healthcare organizations can harness the power of relationships to achieve and sustain high performance over time, building on ideas that first emerged from a study of the flight departure process. While studying American, Continental, United, and Southwest Airlines in the 1990s, I found stark differences in how pilots, flight attendants, mechanics, gate agents, ticket agents, operations agents, ramp agents, and fueling agents worked together to ensure the safe on-time departure of flights. At the time, many people in the northeastern United States, including myself, had never heard of Southwest Airlines. But I soon discovered that the way employees worked at Southwest was dramatically different from the other airlines, particularly the ways they communicated and related with one another regarding the coordination of flight departures.

I called this relational coordination: coordinating work through relationships of shared goals, shared knowledge, and mutual respect. With the help of colleagues at the MIT Sloan School of Management, I created a method for measuring relational coordination. With the help of colleagues in the MIT Flight Transportation Laboratory, I found ways to measure the quality and efficiency outcomes of flight departures. I discovered that relational coordination was a powerful driver of both quality and efficiency outcomes and that the high levels of relational coordination found at Southwest Airlines enabled employees to shift out the quality-efficiency frontier that constrained their competitors. Furthermore, I found Southwest had achieved its relational coordination advantage by adopting a unique set of high performance work practices. These findings were documented in The Southwest Airlines Way: Using the Power of Relationships to Achieve High Performance, a book that has been read by employees and managers in the airline industry and beyond.

The relevance of relational coordination is not limited to the airline industry, however. While studying the airlines, I found myself in the hospital for the first time as a patient, with my husband, giving birth to our first child. The day after I gave birth, care providers were in and out of my room constantly. One nurse would come into the room and explain something. Another would come in later and say: "I know you just heard about a, b, and c, and I want to reiterate some of that, but also to let you know about x, y, and z." After this had happened several times, I said to one nurse: "I am really impressed with your coordination. Have you been working on this?" She told me: "Yes, we've been doing total quality management." I was even more impressed, but when I asked, "When is my doctor coming?" I was told, "Oh, we don't know; they never tell us anything!"

Clearly, something was wrong with this picture. It was the same problem I had observed in the airlines. There, flight attendants, pilots, mechanics, ramp agents, and customer service agents tended to have a relatively easy time coordinating with their colleagues in their individual functions, but when it came to coordinating with colleagues in other functions, it was a different story. Whether or not they liked each other on a personal level, their lack of shared goals, shared knowledge, and mutual respect undermined the quality of their communication and created barriers to effective coordination.

At that moment, I was determined to explore relational coordination as a potential driver of healthcare performance and explore how healthcare organizations could foster it. What I discovered is summarized in this book. The bottom line is that relational coordination is indeed a powerful driver of quality and efficiency for healthcare organizations. Consistent with my experience that day in the hospital, however, physicians are often a missing piece of the puzzle. This is not due to the personal failings of physicians but rather to the way healthcare work is organized. Organizations that want to strengthen relational coordination will have to assess their work practices as they relate to all care providers, including physicians, and transform those practices that are creating barriers to relational coordination. This book will show them why and how.

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