Kathy McDonald, Ph.D., M.M./M.B.A., presents at the Johns Hopkins Department of PM&R’s Grand Rounds on May 26, 2021.
I'm very, very happy to get to meet this group. I think that there's a lot of overlaps with my interest areas and at the opportunities that you have in your area of work. So I hope this is the beginning of a long relationship and you'll see that relationships are part of the content of coordination. I'll just give you that preview. So you can be thinking about that as I share some of my thoughts about this area of how to coordinate care across the continuum of care and using research in practice. Well, I don't have any conflicts of interest. And what I'm hoping today is that and all of us together, we'll learn about more deeply. What is coordination? What is care coordination? What is the care continuum? And how does care coordination, bridge that care continuum. And then what kinds of practical tips might be take homes from relevant research in this domain? Really. The intersection of these domains. I wanted to start with just giving kind of easy picture of what care coordination is. When I first started working on care coordination, it was about 2005, so quite a while ago and it was becoming an area that as a nation we have prioritized as cross cutting and important because early evidence was showing that gaps in coordination of care. I've had real consequences for patients and for the value of care delivered. So the first question is, you know, what does anyone think about when they think about what is care coordination? What would be the active ingredients of coordinating care? There's a lot of words that have come up through the time that I've worked on care, coordination in terms of what people think of care, coordination. This is not research, this is just the download, you could adwords if you wanted. I've made some words a little bigger because I know they come up more frequently, so communicating, organizing, meeting patient family needs synchronizing, but really at the base of care, coordination is care. So why don't we? Can't forget that. And in that early work, um that was a constant challenge. Is how do we scope what care coordination is when it really is everything. But you're gonna work in an area and you're gonna do research in an area and you're going to try to make improvement in an area. It's helpful to try to define it all right. Like fewer words and with something that's more sentenced. So we worked on that in the early work as part of an evidence based practice center project on closing quality gaps and worked on trying to define care coordination and being evidence for focused researchers. We decided to look and see how others had defined care coordination and found over 50 unique definitions. Those definitions were brought together to give us a single definition that's actually cited quite widely. Uh and it's often referred to as H. R. Q. Uh definition, which it is. They commissioned the work and uh and we we we just did the activity and needed a definition for the rest of our work, which was to look at what the research was on, how coordination was actually affecting care. But perhaps this was a working definition used to be able to find the right literature to understand how care is coordinated and well from interventions, but I want you to pay attention to certain parts of this definition and um we'll break it down a little bit further because before writing this definition and going through a whole feedback process with the technical expert panel, We looked at what was in common across those 50 definitions and found five main things that were in common here. I've bolted more than five areas, so I would focus on coordination is deliberate organization. It's not just the free for all that happens to coordinate care. It involves all of the patient care activities that occur between people, participants in the care, um that care includes the patient, so you can see that there's hardly any activity that wouldn't require some coordination between at least the patient and a care provider involved in a patient's care to facilitate the appropriate delivery of health care service. So there's a goal, there's a desire to make sure that appropriate delivery of services occurs. Further organizing care involves marshaling of personnel and other resources. So the resource effort I'm needed to carry out all required patient care activities. It's often managed by importantly the exchange of information among participants, responsible for different aspects of care. I probably should have folded responsible too because how responsibilities are apportioned in care, coordination is often quite invisible. And where a lot of the difficulty lays, that's another foreshadowing that they mentioned. We looked at all the definitions and we're able to he's out five common elements or at least five elements that some of the elements were in some of the definitions, not necessarily all five elements in all definitions, but once we have these five elements, we we had a pretty exhaustive list of what was needed to be considered in the definition for care, coordination. So this idea of the numerous participants, the idea of the fact that the participants are dependent upon each other to do desperate activities. The idea that to carry out activities in a coordinated way participants need knowledge about their own and other's roles and available resources. The synchronization of resources, the marshaling resources and the fourth in order to manage all required patient care activities, participants rely on exchange of information and five integration of care activities has the goal of facilitating appropriate delivery of health care services and that may seem just so obvious that there has to be a goal. But surprisingly many of the definitions did not get at the at the goal. Now I want to turn to this other concept that's related and ultimately bring them together because in the area of clinical care that I everybody in this department does the continuum weighs heavily. The continuum from Webster's dictionary is a continuous hole quantity or series a thing who's parts cannot be separated or separately discerned. It's very interesting because when we think about the care continuum and healthcare, we often think more about the separate pieces that might be drawn together, but not necessarily that that they are integrated and working together because they so often do not actually integrate. Well, we have such a fragmented healthcare system for more reasons than anyone could cover and even beginning of an hour. So I know we all know about it Still in terms of thinking about the continuum of care from a healthcare perspective, I like I like this definition that came about in 1997 from a really fabulous nurse researcher, jerry, lamb and this is kind of on the cusp of managed care. So it was the idea of how we're gonna manage care which with more, of course they uh payments model as as well as well as the delivery model. But here what she has defined continuum of care and interrelated array of services from primary to tertiary care, from community and ambulatory services to institutional services. And back again, this continuum has been pictured in linear and circular forms, usually with extensive feedback loops and I'd didn't put bolts in here, extensive feedback loops. Clearly part of the challenge in a continuum of care. Another aspect of the continuum of care that the same article covered and I I believe it's really important to appreciate as we move into more and more towards ideas of population, health and value based care is the notion that if you're going to try to, you know, visualize this continuum of care and then perhaps figure out, you know, how well health care team or system or any effort is doing in terms of delivering good outcomes across that continuum think about the the areas of of effort and and work to care. And then the possibility of looking at the outcomes. You can look at the level at the program level that could be, you know, a unit, the I see you as the patient comes in your own house, you could you could look at a particular program, an approach that's being used, you know, for a particular patient population, you know, we're going to try to get patients seem more quickly um and and put effort there, put process improvement there and that's our um our our program level efforts. So it can either be institutional boundaries or it can be boundaries by the scope of work at one level where where outcomes could be measured. The next level, where outcomes could be measured would be around transitions of care. That's clearly part of any continuum of care and I'll get into that more as soon, you can think about a more global level, like when you integrate across entities, um what are the outcomes across entities for a given patient or you can look at population based indicators. So for populations of patients across everywhere that that the patients in that population get their care. So the idea of the continuum isn't some static concept. It's it's something that you have to put the boundaries around um in order to think about how to research it and how to practice in that continuum. But from a patient centered perspective, the bottom line is does all the care occur in a way that that is holistic where all those parts are actually drawn together and integrated? I've been trying to learn a little bit more about the work that I believe all of you are participating in and doing. I spent some time on one of the that looks like one of the professional organizations sites and listen to some talks and found this really gorgeous diagram uh that was done during that was a mural created during a series of talks that I listened to about and I I would love to be able to people use the hand thing if you've seen this, if you could throw the hand up there just so I have a sense of whether this is new to anybody or if this is something that's that's commonly understood how to think about. Okay, we're seeing seeing one hand, there are a couple of hands. Okay, great, thank you for being a little interactive with me. I am. But what I what I found very appealing about this particular way of capturing how field of physical medicine and rehabilitation thinks about its place in patient care is that I could look at this diagram and I could listen to the talks and I could hear where the incredible challenges and opportunities related to coordinating across the continuum sit. So they're right in the middle of this was to explore new models um in acute and post acute continuum, like what are the models of care? How do we make sure to give care across the continuum and what key role of psychiatrists and the team that they are leading and facilitating and catalyzing play and how the future but needs more more of you. That that I bought that, I definitely bought that and then I got very intrigued by what have I learned in my research career that would be applicable and useful in in your world. So this is where my motivation came, came came through more deeply. I was already very intrigued and very thankful to be invited to talk to you. But I'm looking at this, I could see the challenges that are faced and the ways that the psychiatrists and the community around you are thinking um it's very appealing and interesting. So, on this diagram I'm leaving this diagram up for a few minutes since they weren't like a zillion hands. Um you'll see down in the bottom right quadrant there's things like communicate, there's things like, you know, putting the pieces together. Um and then over on the left side, you know, there's there's a bit about address gaps and and then there's there's some bit about targets and meeting goals, which of course relates to what I was saying about care coordination. How can you meet any goals without addressing those gaps and coordinating, communicating. So good team was down there in that bottom right side too. Every part of this could relate to how to how to deal with the continuum through the lens of coordinating care, which gives me to the next collection of of what I want to convey, which is thinking about how care coordination of the work that's been done on care coordination is critical for bridging that care continuum. How working with the net care continuum and making sure that for patients it's as smooth and seamless as possible and is felt as a whole because that's the idea of um lobsters definition what I've integrated here in terms of what I've worked on over the years is a is a pretty short list of what I think is worth paying the most attention to thank you if you have an interest in bridging between what we know about care coordination and what you experience in terms of playing some role across the care continuum, but pension to gaps is really big in the early days of getting involved in care coordination, I, I was working with, you know, various clinicians, people in organizational science, the area that I draw a lot of my um expertise from management and again and again the issue of where are the gaps that we're trying to bring those separate pieces together and this makes it just may seem obvious, but sometimes you have to state the obvious um and put at the top of the list and then you know, what health entities are involved. So, you know, we could put our blinders on and just look, you know, narrowly um at at one entity or a workgroup within an entity or we could look across many entities, but it depends on what it's trying to be accomplished in terms of with the question, what entities are involved in what, what we're trying to accomplish another area of focus that I believe it's it's pretty important. It was part of some of the early measures of coordination. I had to do with transitions, managing transitions and noticing again back to the gaps. Whether the transitions basically hold will reduce the width of the gap, Maybe even shrunk it to nothing if it was an amazing transition management approach and being able to see where there were lesions in the transition measurements. Another area that I've done a lot of work on. So I'm very biased. I believe measurement can be useful at the patient level in terms of the feedback loop that's needed to see um how the patient is progressing. but measurement of the various systems is also uh powerful. As long as it's done well, it can be done very poorly and cause more harm than good. Just like medicine, you have to be careful but including granular care coordination measures to assess success within domains of coordination and I'll get into this idea of domains of coordination. Also the central role of teamwork and communication also can't be understated. It's a it's the bread and butter of coordinating care across the continuum. I wanted to show this visual also another pretty visual uh which is what what I refer to as a visual definition as as my team which had originally thought about what's the definition for care coordination. And then worked on understanding what interventions have been done in care coordination and how, you know, some certainly contributed to better care um and higher efficiencies. We worked on looking at the entire landscape of measurement and care coordination. Who had measures what the measures were, um how well they were working and created a care coordination measures atlas and in that atlas, which was updated also, we developed this visual and then some cases to describe what's going on in this visual and the key part of this visual, even though um I would usually say the key part is right in the middle, meeting the patient's needs and preferences and the delivery of high quality, high value care, I would usually say that's the key piece of this diagram. But for our purposes today and for our talk today, um, we're not going to get there unless we appreciate the white spaces between the the various activities and care touch point. So whether it's, yeah, the big clinical areas like primary care or one type of specialty care versus another type of specialty care. Um, whether it's an activity like understanding of medical history or getting to the point of having test results or or a domain like home care and what's added here and is not in the care coordination atlas's insurance because certainly the management of how care gets paid for becomes something that can, you know, be a barrier to being able to coordinate care well or being incentivized to coordinate care well, in terms of the payment models that come through on that mechanism. So the key here, from the perspective of of bridging between the continuum and what we know about care coordination is the white spaces. I don't want you to appreciate that there are a lot of white spaces and you could add a lot more circles and you'd see more white spaces. I've mentioned a few times the idea of health care entities that play distinct roles and perspectives matter and health entities. And in this slide, I switched my slides up, it says again, health perspectives matter again and I'm going to get into perspectives separately because I decided that it would actually be helpful to think about the entities first. And uh we can to get to the point of being able to coordinate care better, just like body systems. You need to have an appreciation for the numerous entities that exist. If you take a patient centered perspective or if you take a health care professional perspective or you take more of a systems administration perspective. Um It's easier to see some entities rather than others. But the whole picture emerges when the list of entities uh is developed by those three perspectives. I got to play this out a little bit. Um You know, the patient and family perspective entities would be something like my individual health care provider that I'm interacting with a nurse, a physician support staff. If you're a healthcare professional and you think about that perspective entities might be on my work group, you know, my nursing workgroup, my physician workgroup, my support staff workgroup, my clinic. And you know, there could be like provider groups, my primary care practice, my specialty practice urgent care clinic. So there's some overlap there, but you can get the idea of depending on um which which person you put yourself in in the head of. Um and then try to describe what the entities are. Um It could be, you could stick the bit and then from a system perspective those who are trying to like put it all together in some way or at least support what's going on entities would maybe be like the groups of providers that act together in a unit, a medical unit in the hospital, the hospital as a whole, especially clinic within an integrated system, different clinical settings within the healthcare system overall. So like all of the ambulatory care, all of the inpatient care, all of the emergency care. And then if you want to scale it up even further outside of the unified system, the picture gets even more complicated and that's where thinking through the lens of transitions and how transitions are managed is another analytic approach to laying out um What the challenges are in some sort of boxes that can allow action and and feedback loops in terms of being able to measure what's going on and and observe what's going on and try to intervene and change as necessary to make the work work in a more coordinated fashion across the continuum. So I highlight um remember that list. I had gaps. Um And then I had transitions. Management transitions relate two entities and they relate to time. So so think of transitions as these points. Uh And there are points where information Um and or accountability and responsibility for an aspect of the patient's care is transferred between two or more entities Or is maintained over time by one entity. There's a play of time and there's the the issue of entities in terms of what ah triggers a transition and there's there's some details here. I won't go into them. You live this, you know this but from a analytic perspective and trying to make improvements perspective. Um Just emphasized the idea of transitions are related. They can be related to entities and they can be related to the passage of time or some combination there. As I mentioned, I changed up my slide order a little bit and left this idea of the different perspectives um and the details of that for now instead of originally because it's easy to say there's these different perspectives but it's it's better to be able to to stop and think about when they matter and why they matter and just to tell you, oh they matter. Um You can't think of care coordination, you can think about integrating across the continuum without sitting in different perspectives. The whole picture isn't there? Uh And so by giving the examples of the entities and the transitions, I think it's easier to appreciate how critical it is to have a multi ah area perspective lens. And this came up in working on measures of care coordination that we needed these different perspectives because the measures that exist often focus on just one perspective, The data sources one perspective. So if you ask patients or their family members and I say family, it can be any informal caregiver who's you know, friends, family. Um You can survey patients or caregivers about their experience of coordination of care. You can also serve a healthcare professionals Survey one Type of healthcare professional or another, um or teams of health care professionals. Um you can ask healthcare professionals to reflect on their own actions and caregiving practices. Um, and have that be kind of an audit oriented sense of on how coordination is working as a line of visibility or a not, not quite a quantitative measure unless you've been in which you can, that's another way that some measurement work works. And then this idea of the systems, the person or the folks who are representing the system administrators, leaders who have some responsibility for the whole unit or a whole group or a whole uh target of activity like a particular patient population and again, a data source for measures because I've said it's helpful to have measures at a granular level of care coordination. There are measures that are surveys of these kinds of folks. Uh, same clinician leaders can respond on behalf of their organization, not their own specific actions. The medical record has information that can be used. Um And administrative claims data has been used also in terms of thinking about handoffs and and and other metrics, harder to get out the details of coordination and administrative data, but but there's some measures that come from that data source and there, I would mean, you know, being able to look across more across different groups and because you have more common information across groups. So higher level analysis and keeping the focus on measures for just a little while longer because I said that's something to pay attention to that I know in your area you pay a lot of attention to the idea of of the patient's trajectory over time and being able to monitor how well the patients functional status is improving over time, but the same can be said for looking at how well the coordination that allows the care to happen, happen in a synchronized way that allows the patient to get what they need to end up getting the outcomes that you want for them. Ah We have to we have to be able to parse this idea of coordinating care in order to measure it, not just one big concept, just like you parse the idea of functional status and other ways that you get a line of sight on how all the patients doing. You can be biologic, there can be observation, there can be a lot of ways of looking at the patient, there can be a lot of ways of looking at the system. So, you know, in this work, this was again related to this atlas of care coordination measures where we were looking for who's tried to measure care coordination and how they measured care coordination and how can we assemble all of the evidence on these measures of care coordination in a way that is accessible and and and also advances our understanding care coordination. So we developed a framework for measurements and and created these categories. I was subcategories of care coordination based based on again, integrating a lot of some other research at the time and this also has had some staying power. So uh I hope this is helpful to you, but the idea that coordination activities are one area where you could think about the domains, the subcategories of coordination. So things like establishing accountability or negotiating responsibility for a particular and activity set that would be coordinated together, communicate. Um and and there's actually sub categories of communication facilitating transitions. one that that is prominent in a lot of work where complex care is being coordinated is the idea of as a proactive plan of care. What is the plan of care? And has that been? What has it been use? What is it? There's various ways to ask questions about the plan of care um and so forth. This this last one on this list of coordinating activities aligning resources with patient and population needs. And actually the one before two linked to community resources came more out of the pediatrics world working with kids with special health care needs. So pretty complex patients over a long period of time and the idea that not everything is limited to the healthcare um domain. I think the learnings there in terms of coordinating care can be useful as we think of aging populations and other high high complexity environments. We also developed some domains related to an idea around like broad approaches, efforts that were being made to coordinate care, targeted coordinating care and and so there are measures that were developed around that things like teamwork, health care, home in the primary care setting, care management at the time with big medication management has persisted and health I. T. Enabled coordination. So the broad approaches were a bit more linked in time to when we were evaluating what measures existed and and wanting to map those measures to areas that that people were working on And and this is just to give you a slight sense of what's out there in terms of care coordination measures uh from the update which was done in 2014 or funded that and they haven't funded an update since. Uh we uh we found 101 measure instruments that assess multiple domains, most measures that relate to care, coordination. Ah some either care coordination as a whole or parts of care coordination. That I've shown you are pretty agnostic to the clinical domain. I mean some are some are targeted right there, you know, melanoma care but many of them are cross cutting and would be useful in in any environment. And what this shows is it just shows for those 101 measures how many measures ah Have within their measures. Many measures, our survey measures uh something that relates to the sub domain, so you know, 50 or so out of the 101 measures, about half have at least, you know, one question, possibly more questions on um something related to this idea of accountability and responsibility. Many have 90% have something related to communication. It's actually surprising that there's any that have what we don't have any information about communication, but you can see that that's um this is kind of what lays out in terms of measurement and the care coordination atlas has these measures and has the map to the domain. So you can have a quick look at whether a measure of coverage domains you might be interested in. There used to be a searchable database, but unfortunately it's not available anymore. And now I want to turn um you know, I've been talking about some of the research I've been involved in and how that's been boiled down in my mind and what I've been trying to do in terms of giving that the mental picture of breaking down both the context of the, across the care continuum and the the effort to coordinate care. I now want to want to give it a little bit or extend, I should say extend what I've been talking about to highlight. Um some of the work that's been done in, in an area of care coordination that I have found from the beginning of my work in this area. So for the past Uh you know, 15 plus years to be very powerful and it has continued to become, I believe more and more understood as important. And then the the willingness of any group to start to draw from this area that I'm going to talk about is something that I don't think I've seen a group yet and I've been involved for a long time and kind of the collaborative world that cares about this area of work, I don't think I've seen any group that hasn't found something from this very useful. So I'm going to go go deeper into one part of the research space related to an approach to coordinating care, which is been called relational coordination. And that sounds kind of, I don't know, touchy feely, but but actually it's it's it's not the soft stuff, it's it's pretty, pretty cool and it relates to teamwork and communication measuring and intervening. And as I said, there's a, you know, a growing application of this. So the community that's, that's involved in drawing from relational coordination concepts, has uh has tried to share what they've learned, you know, like a professional group, it's, it really is. Um but it's a group that's, that's comprised of people who are practitioners and people who are researchers and people who blend between the two areas. So it's it's both very practical and very much about advancing theory and measurements and I'm very hopeful that I've come from and live from stanford fairly recently. And all right, took my community there many years to start to notice that it was useful and could be helpful. And I've been gone for about a year and a half and I hear that now going gangbusters with this and I can only hope that I was planting some seeds and now I'm hoping that the seeds here at Hopkins sprout a little faster because there's, there's a lot to be learned from from this kind of advantage point. So let me dive into this area as a way to translate research into practice and just just to give you a little bit more background on myself since I'm partly being introduced to the Hopkins community by having a chance to talk to different groups, the areas that I've spent real time in in this area of research have been first and foremost, having discovered this set of ideas in that early work on defining care, coordination and understanding what the theory was and how to relate that to interventions and measures. Um I found this work when it was pretty new and early um from a researcher at BRANDEIS who had studied the airline industry and come up with this concept of relational coordination and it hasn't been applied to health care too much at that point a little bit. It was promising, but it um it was relatively new at that point and as as I started finding out more about it and working with other people in it. I was part of the group that that started to create more of a collaborative around the concept um to generate shared learning over time in this area and so it was called the relational coordination research collaboration and you know, to have like conferences and have resources together um so you know, kind of a membership organization but also very open and trying to be public facing and and have um the knowledge that was accruing be available uh in in this community as well as as outside. Um it's it's recently changed its name to the recent relational coordination collaborative RCC two try to make sure there's not this big distinction between research and practice and um it moved from being kind of shepherded and stewarded um at BRANDEIS University where jodi um copper kettle is a professor to the University of New Hampshire where another of one of the early leaders in this area, margie Godfrey has recently moved and has set up a way to be able to continue to provide the glue for this collaborative and I've been the advisory board chair for quite a few years now and was was, as I said, part of it as well as it was the developing community of researchers and practitioners recently we've put together a memorandum of understanding to make sure to be concentrating on the research aspects of this across the two institutions that have hosted this collaborative and john Hopkins, but the little background just to tell you this is an area of serious, serious interest of mine. And so what I share with you, if any of it, it seems applicable and useful, feel free to come back to me for more. I'd be glad to work on problems in this area from a strong marriage between practice and research. I've also just got up here a few things about, you know, working within the V. A. System on care coordination and uh trying to translate between what we know and research and what we know in practice. And there's a couple of papers on that and yes, I'm areas other areas of work, thinking about time pressure and how that works within team dynamics and patient experience. Um and finally, I've, since I've gotten here, I've had the pleasure of working with a group that wasn't too far field from your group and that's the brain rescue unit. And so there's a project underway and there's a few slides where I pop in um from from work with them, they're they're working on bedside rounds um intervention and measuring care coordination through this lens of relational coordination as well as other teamwork approaches. Let me um let me just give you a a short but high level view of this, the set of ideas around relational coordination as a it's a good translation from research and practice. So first of all I mentioned that this came from the airline industry 1st. And so when this was done in the airline industry, the idea was getting people from point A to point B on a plane. And so in the middle of the vast network of various roles that would have to be coordinated to get each of us from one point to another on a plane. Um so things like baggage handlers and pilots and so forth, was was yeah, the customer, a person flying here in our healthcare application, patients and families are at the center of all of the work, all of the activity that's being coordinated and you know, this these bubbles around this, basically social network are the roles that can be active for uh for care. And you could fill these circles in with any definition you want of any role that's flexible in terms of thinking the key here is that different roles are involved in coordinating care where work is interdependent across the continuum. Another way to view the challenge. Besides just that, you know, it looks like practically a spiderweb um is to break it down into more of, you're familiar with the dawn obedient quality of structure, process outcome. Uh you can break this idea of the challenge of coordination down into their structures. There's within unit structures, there's outside of the unit, how you might coordinate across units. Then there's the processes that relate to coordinating care and the people in their roles instead of looking at it just at the individual person level. But looking at the role level is a way to activate interventions and change and, and processes that are more sustainable. You're not all dependent on one person doing things in one way. And so thinking about through the standard approaches um at the workflow level and and other um aspects of the process of coordinating care and and what I've got here down in the bottom is the work situation of the task. It's something that's sometimes underappreciated also is that the structures that are needed and the processes that are needed to get the performance outcomes related to, you know, what is better for patients and what's higher value. It's sustainable for a system sustainable for those working in the system, the the way to get to this performance outcomes, what needs to be set up, It's going to vary depending on the specifics of the work situation of what is being accomplished through the task. So, 11 way to think about this is, you know, when you diagnose a patient, how complex the patient is, that there's multiple um, you know, conditions underway, multi morbidity and versus, you know, a single singular Challenge, you know, 1, 1 injury, one set of of treatments that are going to happen and make the patient well, the idea of looking at a work system and thinking about coordination. There's been a lot of work that shows that these three elements of the work situation or set of tasks that are most predictive of how much coordination is needed, like the dosage of coordination that's needed and the fit of one form of structure of one form of processes with what's needed to get the outcomes is how interdependent is the work that's done among different roles and keep remembering that the patient is part of the team, uncertainty, how much uncertainty is there? If there's more uncertainty than the the level of effort around how to coordinate and the ways to coordinate are going to become more uh more nuanced and um time constraints. So the more there's time constraints, the more severe time constraints. Again, the set of coordination processes and the structures that need to be in place have a different a different set and I just like to use the word more powerful set of more intense set, like a dose response. And there's research that shows that relational coordination is as a concept at the core, very helpful for moving from like less being useful, less interdependence, less uncertainty, less time constraints to higher levels of all three of those. So it becomes more and more important as you get higher levels of those, those three because there's more roles who are combining their work. They're interdependent work and there are more time constraints and there are more uncertainties. So it's a concept and it's a way of approaching the problem of trying to make coordination better across the continuum that can work from that that lower level of of task challenge for coordination up to higher levels, but it's particularly useful for as it gets, gets more complicated. So I've been talking about relational coordination, you've had a mental map of what you think it is perhaps. Uh and now I'm gonna let you know how it's defined in terms of when it was first observed in the airline industry comparing different airlines. So, dr Patel gave it to this, created this definition a mutually reinforcing process of communicating and relating for the purpose of task integration and what's been seen through the research is that improved team and system performance. When relational coordination is stronger and relational coordination has to do with the relationships and communication, you'll be seeing these a few times over the relationships break down into are there shared goals? Is their shared knowledge and their mutual respect and the communication elements breakdown to is the communication frequent enough? Is it timely enough? Is it accurate enough? And is it problem solving enough for the task for the work situation? And then worst team and system performance is seen when you have left the beach of those And so relationships maybe just have functional goals? They don't integrate knowledge gets pretty exclusive and there's a lack of respect. These are all hallmarks of poor relational coordination and uh and are associated with poor levels of performance and similarly on the communication side of the relational coordination concept. Yeah, in two and frequent to delayed too inaccurate and blame shifting communication instead of problem solving communication are are markers of us what you're going to see as poor performance. And here I bring in a slide, I'll bring in a few slides from the work with the brain rescue unit work where they're using relational coordination and um and they've pulled together this idea of the for better and for worse approach of of what you know, from relational coordination and this idea that we're communicating and relating for the purpose of task integration and that relationships are shaping the communication through which coordination occurs. And as I said before, we can we can focus Not just on the personal individual level, but we can focus on the role level two. The construct of relational coordination is that it's a measure of the network level, the network of ties among stakeholder groups and uh any time it's used, the group figures out who the stakeholders are and decides what boxes to put them in and develops the survey based on that. The survey is a seven item validated tool to get at those three relationship concepts and the four communication concepts and as I've had workers rolls part of the measure and part of the concept interdependent tasks as part of the measure and um it can work across clinical domains, it's been applied outside of health care. Um, a lot and there's really significant research on the construct and its utility. So there's a very recent systematic review of 233 studies. Um And there's a new RC interventions database, two of many interventions that have been done in this area. So again, another slide from counterparts within the johns Hopkins system that just shows this idea of the sort of feedback loop loop between the relationship aspects of the construct and the communication aspects of the construct measuring R. C. Uh These seven constructs down the left hand side are asked questions are formed to represent each of those constructs and they're tailored to the particular work situation. So here is an example um for post operative care procedures for surgical patients until you'll see that coming through each of those seven concepts and I um pulled pulled in the one that's just been done for the brain rescue unit. Uh And so here the work situation relates to the patient's care plan for the day. So how frequently do people in these roles? Um So I'm in one role in I was asked for, do I get what I need from somebody in another role? And the physician do I get what I need from the nurse and the nurse. Do I get what I need from the physician? Um You know, how frequently do people in that other role communicate with me about the patient's care plan for the day. I'm also asked about it from the perspective of others from within my work role. And that creates the data set of how the the varying work roles are in diabetic form, what levels of communication they have on these four dimensions and what levels of relationship factors that matter for getting the work done um that exists in the brain rescue unit. Here were the roles that were surveyed. So again, there's a lot of tailoring. The group had to spend time figuring out how they wanted to consider who the stakeholders were that might be affected by bedside rounds and who might be affecting the ability to coordinate um through that mechanism and the and the care, you know, having the care plan for the day. So this was the set of groups, but it's up to any group that's trying to focus on a particular area of coordination um to decide what the roles are. And it can be done within a unit like this, or it can be done across units or across even entities if entities get together to think this way and and this is, you know, without data, but the idea of, you know, each group is saying on a five point like scale for each of those questions, whether they're constantly never versus constantly and everything in between having that element, the frequent communication problem solving communication etcetera. And then um from that data, uh and and I'd like everyone to think also about, you can do this in a numerical way um or or banding it as sort of weaker relational coordination of the stronger coordination at this from these concepts of relational coordination. You can also I've seen this used pretty effectively in early stage work uh without actually doing the measure just having groups and I've done this in my research teams to ask themselves questions about, you know, okay, here's the roles. Um how do we think our roles, the roles are, are communicating with each other, what do we think the shared knowledge is etcetera? So so you can use these concepts qualitatively or quantitatively and um but if you do it quantitatively then um from the survey, these types of pictures come out and they can be very helpful to being able to sit down with a group and and have a status through the current state of one workgroup to another. So the this this what this means here is like the red workgroup is within themselves weaker and the green workgroup within themselves, it's very strong and the colors that connect are related to how the diet works. And you can get the network findings um in this and you can get a matrix of findings in this to see every pair how they work in diabetic form. And and then I'm going to end on this because I know we're at that point of of having to end but um and this is the ps to resistance from my perspective in terms of applying relational coordination to a work area. Uh And so this is the idea of the general approach for bridging the continuum through R. C. And the roles lens is that their structural interventions on things that often middle and top leadership would be considering and can intentionally focus on in terms of how it supports higher level of the relational coordination. There's this concept of relational coordination in the middle and there's the performance outcomes that we care about on the right hand side. And then undergirding all of this are actual relational interventions, things like humble inquiry coaching, creating safe spaces, the idea of, you know, the culture of safety or cultures that lead to higher quality and then the work process interventions. I mean it could be things like lean and regular quality improvement, but through the lens of understanding the current state of this interdependent work done through roles and identifying the desired state and looking at the gap. I mean that's that's a very frontline um activity. So it's the front line workers, it's the frontline leaders, it's the patients, families, whoever the quote client is that's co producing their own care, looking at what's happening, relational lee what's happening in terms of work process but it has to be supported by structural interventions and um and then when work is done in each of these areas, you get higher performance and the systematic review that I mentioned has a lot of detail about this. So I recommend it if if you're interested, I'll conclude there um and thank you for your attention and I hope I get to meet, meet you all in person at some point. I think greedy and I've gotten to meet her in person. So I sort of I guess it actually hasn't been in person, it's been all this way it feels in person over time. Thank you so much. Kathy, this is awesome. Um just to let everyone know, you know, I came across Kathy's work and I felt that it was so integral to what we do in PM and R um because we are constantly looking to sort of bridge the continuum and make sure we shepherd our patients through all of the transitions and there are just so many opportunities where things don't go well, right. And especially as we move towards implementation science and implementing best practices that have that are now out there in the research and have to be incorporated into clinical practice, I think what you are, you know what you've presented become so very relevant. And so I guess my I know we're running out of time. So I just want to ask one quick question, if somebody wants to get in touch with you to know what would be the mechanism to sort of say, okay, you know, we have a project and we would like to sort of a veil of relational uh coordination. Yeah, yeah, I was thinking about that because I just think this area we could learn so much together, so, you know, I just say reach out to me and we'll figure it out, you know, I've been interested in, the brain rescue unit has been actually working for a couple of years. They brought together, you know, varied folks and are meeting regularly and have um you know, gained a lot from these concepts and you know, I've also worked with, you know, others at other universities who are trying to draw from this, so I can be a bridger, I can be an active participant in project, you know, there's so many ways to be involved, so I'm I'm actually very eager now that I've learned more about thank you pretty for the noticing the connection because I I'm sure that we could do a lot together and learn a lot together and make a real difference for the patients and the field, so get in touch, you know, email me and all. You know, we can meet, I can meet in group, I can meet individually whatever whatever works, but I'd be very oriented towards making a difference. Thank you Kathy, any other questions from the group? I hope it's relatable in some way, that's that's my main mean, hope I think people have a clinic starting at one o'clock, so um thank you again, Kathy, you know, I'm sure you will hear from a few folks um and we look forward to working with you. Yeah, and I'd be happy to come back any time to, you know, do sort of a Part two, I think that there's a whole range of work of thinking about the co production, you know, with the patients and families and this idea of the relational coordination in the middle among all the workers and the relational leadership that's needed in terms of at the higher levels of an organization. So really powerful concepts. And be glad to spend time in this format if there's an interactive way to do it in this format. Happy to do that next time too. Thank you so much. Thank you.
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