Lack of Coordination Hampers US Health System

By Jody Hoffer Gittell, Posted August 20, 2009 in ModernHealthcare.com

The issue of universal access has taken center stage as Congress, powerful industry players and millions of consumers debate the future of healthcare. Could it lead to healthcare rationing and diminished quality of care or prove unsustainably costly? There is some truth to both scenarios—if we increase access without remedying the way we deliver healthcare.

The truth is that despite having some of the best clinicians and health policy analysts in the world, the U.S. healthcare industry is failing to deliver cost-effective quality care even to those who already have access. We spend some $477 billion more on healthcare than our peer countries per year, even adjusting for our higher per capita GDP. Meanwhile, we tolerate medical errors that cause up to 100,000 deaths annually at a cost of up to $29 billion. To add insult to injury, a growing number of us live with the fear that we will not have access to care when illness strikes.

Our chronic complaints about cost and quality are symptoms of a deeper problem plaguing our healthcare system, one that has received scant attention from the political players determining the future of healthcare. The fundamental problem is a lack of coordination—how providers work together or more often, how they fail to work together. Patients must navigate a Byzantine system, receiving diagnoses and treatments from a fragmented, loosely connected set of providers, even within a hospital, where resources presumably are brought together to improve the coordination of their deployment.

Moreover, coordination problems appear to have worsened over the years. In 2003, the Institute of Medicine identified coordination as one of the most critical problems plaguing the U.S. healthcare system; a more recent study found that the most common quality problems reported by physicians are related to problems of coordination. As a physician leader at Brigham and Women’s Hospital in Boston explained to me: “The communication line just wasn’t there. We thought it was, but it wasn’t. We talk to nurses every day but we aren’t really communicating.”

Many of us have experienced these problems first-hand. The day after giving birth to my first child, nurses were in and out of my room, each time offering me more information, and each time acknowledging what the previous nurse said. After this happened several times, I told one nurse how impressed I was with their coordination. “Yes,” she replied, “we’ve been doing total quality management.” I was even more impressed, but then I asked when my doctor was coming, and she said, “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. Even if 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.

The biggest challenge for coordinating work cannot be addressed solely through re-engineering or total quality management. In complex systems such as healthcare, work is divided into areas of functional specialization. These areas of specialization often become the basis for dividing colleagues into distinct “thought worlds” with distinct goals, distinct knowledge and distinct levels of status. Although this division of labor can be a powerful source of quality and efficiency, as Adam Smith taught more than 200 years ago, it can also lead to fragmentation and a breakdown of coordination.

When doctors, nurses, therapists, case managers, social workers, other clinicians and administrative staff are connected by shared goals, shared knowledge and mutual respect, their communication tends to be more frequent, timely, accurate and focused on problem solving, enabling them to deliver cost-effective, high-quality patient care. More often, however, these diverse providers lack shared goals, shared knowledge and mutual respect, even when they are working with the same patients, so that their communication with one another is infrequent, delayed, inaccurate and frequently focused on finger-pointing than on problem solving. When this happens, everyone’s best efforts to deliver high-quality care without wasting resources are frustrated. Relationships are an essential ingredient of any workable solution to the coordination problem because they drive the communication through which coordination occurs.

The evidence shows that some healthcare organizations have achieved far more success than others by investing in work practices that support high levels of relational coordination across disciplines. These work practices are not rocket science, but neither are they easy to implement in organizations that are divided by bureaucratic and professional boundaries.

Some leaders recognize that relationships matter for coordination, but until they have solid evidence that these relationships drive results, they can’t get their colleagues on board to make the necessary changes. That evidence now exists. In order to solve the problem of universal access, we must turn our attention quickly to this evidence and begin to address the fundamental challenge of relational coordination. Otherwise we will have achieved healthcare that is accessible to all but whose cost and quality outcomes are simply unacceptable.

Jody Hoffer Gittell is a professor and MBA program director at the Heller School for Social Policy and Management at Brandeis University, Waltham, Mass., and author of High Performance Healthcare: Using the Power of Relationships to Achieve Quality, Efficiency and Resilience.

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