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There are a lot of moving parts here. It's like an intersection in Paris, like the Champs d'Elysee. We have been rooted in traditional medicine, with complex systems and specialization. To shift gears is a huge deal! It's like trying to turn the Queen Anne around: You have to go way out to sea just to turn it around."

Although external pressures help to jump-start the development of relational coordination among care providers, it is clear that external pressures are not sufficient by themselves. The unique high performance work system described in this book is a far more powerful driver of relational coordination and desired performance outcomes. To respond effectively to external pressures for change, healthcare organizations cannot rely on care provider stress alone but instead should engage in deliberate efforts to implement a high performance work system that supports relational coordination among care providers.

Implementing this work system is not rocket science, but neither is it an easy task. In Part 2, we identified 12 distinct work practices. When implemented in mutually reinforcing systems or bundles, those practices can shape care provider behavior in a consistent and positive direction, building high levels of relational coordination. We call this system of work practices a high performance work system to indicate that it is a system of mutually reinforcing practices that work together in a cumulative way to support care provider behaviors that lead to high levels of organizational performance.221 It is a unique type of high performance work system because it fosters the critical missing ingredient that high performance other work systems tend to neglect: social capital or relationships among employees that enable them to coordinate their work.

Because this high performance work system encompasses 12 distinct practices, many of which may run counter to those that are currently in place, implementing it can be a daunting task indeed. Strengthening relational coordination requires changing not just one or two work practices but the whole system of practices. As we know from the organization design experts Michael Tushman and David Nadler, it is necessary to change the whole system of practices in order to maintain alignment among them.222 Each work practice reinforces the others, and so changing one without changing the others increases the risk that the change will not have the desired effect.


Clearly, a systemic approach to change is called for, but systems thinking is not common. More frequently, people tend to focus on one piece of the problem in isolation rather than looking for comprehensive solutions that will address the underlying systemic issues. According to one hospital administrator:

Unfortunately, and I hate to say this, I think that our [staff] sort of look at minutiae and don't look at the whole picture and often don't realize that it's the system that is the problem, and then this ...

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