Association for Public Policy Analysis & Management

Relational coordination across interdisciplinary teams in healthcare organizations has been empirically linked to improved worker and patient outcomes and more efficient use of healthcare resources. New federal policy initiatives have introduced payment models that will require organizations to take broader accountability for outcomes with financial consequences, and improving coordination across interdisciplinary teams will be critical to financial success under these models. Studies of interventions to improve relational coordination are still in the early stages, however. This study assesses an intervention to improve relational coordination in the context of these new payment models. This study used a quasi-experimental pre-post design with no control group. The intervention was 1) the adoption of a bundled payment contract and 2) change initiatives that were carried out by staff in the context of that contract. The outcome of interest was relational coordination among inpatient and outpatient clinical staff, assessed before and after the intervention. Respondents were asked to rate relational coordination on seven dimensions, using the validated relational coordination survey. Responses were then aggregated to create a single measure of relational coordination on a scale of 1-5. A two sample t-test and paired t-tests were used to assess changes within and across workgroups over time. Semi-structured interviews with a purposive sample of staff and ongoing observation were used to assess change initiatives to improve relational coordination. Surveys were distributed to inpatient and outpatient nursing staff, case managers and rehabilitation staff involved in care for total joint replacement patients, as well as orthopedic surgeons, physicians assistants and hospitalists.

The initial survey clinical staff rated relational coordination with the hospitalists significantly lower (3.58 vs. 4.22, t=2.8; p=0.04) than with other surveyed staff. Interviews with clinical staff supported this finding, suggesting coordination of care for complex patients was a particular challenge. Staff developed an algorithm to identify medically and socially complex patients and worked to clarify hand-offs between the surgical service and hospitalists for these patients. A second RC survey shows that relational coordination with hospitalist improved (3.58 vs. 3.89, t=2.35; p=0.06). Qualitative findings suggested that clinical staff better understood patient flow between surgeons and hospitalists after the intervention and reported improved coordination between inpatient nursing and the hospitalist staff. Clarifying hand-offs between surgeons and hospitals and identifying complex patients helped to improve relational coordination across the care team over time. Clinical staff used the relational coordination data to identify areas of need and to support successful work process improvements. Improving interdisciplinary teamwork is one strategy hospitals can use to support better outcomes under new financial incentives in the industry. Relational coordination measurement and feedback can support the improvement of team dynamics.