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INTRODUCTION

In a nutshell, relational coordination is the coordination of work through relationships of shared goals, shared knowledge, and mutual respect.

The basic coordination needs for a patient include getting information from those who cared for the patient previously; sharing that information among the care providers assigned to the patient; keeping one another informed as tests, diagnoses, and interventions are performed; bringing that information together to determine the discharge time and destination; and passing that information along to those who will care for the patient after discharge. These requirements seem fairly straightforward. But as we visited nine hospitals that were working to accomplish the same goals for the same kinds of patients, we observed that the coordination of patient care, like the coordination of other complex work processes such as airline departures, is very difficult to achieve. As a result of specialization, there are multiple parties involved in the care of each patient. As the vice president of human resources at Beth Israel Deaconess pointed out:

Handoffs in the hospital are even more complicated than in an airline. It's not just doctors, nurses, and technicians but all the distinctions among them. We have about 9,000 employees and 4,000 titles. It is an enormously complex place, but we want care to be seamless.

In Exhibit 2-1, the lines connecting the providers indicate that the tasks performed by the different providers were often highly interdependent, meaning that physical or informational outputs from one task were needed for the successful completion of another task. These task interdependencies resulted from the division of labor, the interdependencies among subsystems of the body, and the interdependencies between clinical interventions and the resources used to carry out those interventions.

Exhibit 2-1

Patient Care: A Coordination Challenge

In addition to task interdependencies, there is often a great deal of uncertainty about how and whether a particular clinical intervention will produce a particular outcome. As a result, a patient's reaction to one intervention may give rise to the need for other interventions in a way that is difficult to predict. This uncertainty increases the challenge of delivering patient care. Moreover, the clinical information to be transmitted about patients is often complex as a result of the growth and specialization of clinical knowledge and the multitude of conditions that patients may have in combination. In addition to clinical and administrative information, patients' social information such as their family situation, values, and preferences is potentially critical to their healing. Time constraints further increase the challenge of patient care delivery. A social worker explained:

There's a moment in time when the patient is identified as maybe needing extended care on through discharge. It's time-sensitive because you can't be too late or too early for the window. The window is determined by their functioning, based on lab tests, ...

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