COMMENTARY

Break down walls for better management

A holistic view can improve program management

Steve Kelman is professor of public management at Harvard University’s Kennedy School of Government and former administrator of the Office of Federal Procurement Policy.

If an elderly parent of yours with multiple health problems has been hospitalized — as I have experienced in the past few years — or if you have been in such a situation yourself, you are likely to have been distressed by the problems created by disconnected services in our health care system. The care of patients is sliced and diced by body organ (heart, lung, etc.) and by professional specialty (medicine, surgery, etc.) with shocking frequency and little effort at viewing the patient’s overall condition or sharing information relevant to his or her care among specialties.

Jody Hoffer Gittell, who teaches management at Brandeis University, has written a book called "High Performance Healthcare: Using the Power of Relationships to Achieve Quality, Efficiency and Resilience" (McGraw-Hill, 2009) in which she argues that it is possible to design organizations in ways that encourage the development of relationships. She writes that strengthening such relationships has a positive impact on organizational performance. Issues of coordination and communication are huge throughout much of government, and what Gittell writes has relevance far beyond health care.

She conducted research in surgical units at nine hospitals, mostly in the Boston area, and gathered data about various management practices, staff perceptions of how well people from different specialties communicated and coordinated with one another — for example, the extent to which staffers in one unit believed those in other units shared the same work goals or respected their group — and the extent to which people work across groups to resolve problems. She also collected data on performance outcomes, such as postoperative length of stay, patient satisfaction and postoperative freedom from pain.

What she found through quantitative analysis of her data was that certain management practices at hospitals increased what she calls relational coordination and that, in turn, improved patient outcomes.

The management practices that improved communication and coordination included measuring performance at the team rather than individual level, having more first-line supervisors, establishing a formal conflict resolution mechanism, having care managers whose job it is to manage interfaces across specialties, and setting up procedures for moving a specific kind of case across multiple boundaries.

Two of the findings I found especially interesting were those regarding supervisors and procedures for moving an activity across various systems. There was a period, especially in the 1990s, when the conventional wisdom was that first-line supervisors accomplished little. By contrast, Gittell’s finding is that those supervisors help broker communication across group boundaries. The finding about procedures is interesting because such an activity is relatively easy to accomplish compared with management practices that require greater cultural change — though some professionals resist standardizing procedures for fear they will be stuck with a cookbook approach.

The management practices that Gittell discusses had a noticeable effect on performance. By doubling the overall use of the practices, the hospital extended postoperative freedom from pain by 18 percent, increased patient satisfaction by 53 percent and reduced postoperative length of stay by 68 percent.

The lesson is that better communication and coordination among diverse groups can make a difference in organizational performance. And that's a lesson that agencies could put to good use.

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