Enhancing the Informal Curriculum of a Medical School… · a medical school’s informal curriculum illustrates the ... the informal and formal curricula at Indiana University School

Enhancing the Informal Curriculum of a Medical School: A CaseStudy in Organizational Culture Change

Ann H. Cottingham, MAR1, Anthony L. Suchman, MD, MA2,3, Debra K. Litzelman, MA, MD1,Richard M. Frankel, PhD1,4,5, David L. Mossbarger, MBA4, Penelope R. Williamson, ScD3,6,DeWitt C. Baldwin, Jr., MD7, and Thomas S. Inui, ScM, MD1,4,5

1Medical Education and Curricular Affairs, Indiana University School of Medicine, Indianapolis, IN, USA; 2University of Rochester School ofMedicine and Dentistry, Rochester, NY, USA; 3Relationship Centered Health Care, Rochester, NY, USA; 4Regenstrief Institute, Inc., Indianapolis,IN, USA; 5Richard L. Roudebush VAMC, Indianapolis, IN, USA; 6The Johns Hopkins University School of Medicine, Baltimore, MD, USA;7Accreditation Council for Graduate Medical Education, Chicago, IL, USA.

BACKGROUND: Calls for organizational culture changeare audible in many health care discourses today,including those focused on medical education, patientsafety, service quality, and translational research. Inspite of many efforts, traditional “top–down” ap-proaches to changing culture and relational patternsin organizations often disappoint.

OBJECTIVE: In an effort to better align our informalcurriculum with our formal competency-based curric-ulum, Indiana University School of Medicine (IUSM)initiated a school-wide culture change project using analternative, participatory approach that built on theinterests, strengths, and values of IUSM individualsand microsystems.

APPROACH: Employing a strategy of “emergent design,”we began by gathering and presenting stories of IUSM’sculture at its best to foster mindfulness of positiverelational patterns already present in the IUSM envi-ronment. We then tracked and supported new initia-tives stimulated by dissemination of the stories.

RESULTS: The vision of a new IUSM culture combinedwith the initial narrative intervention have promptedsignificant unanticipated shifts in ordinary activitiesand behavior, including a redesigned admissions pro-cess, new relational practices at faculty meetings,student-initiated publications, and modifications ofmajor administrative projects such as department chairperformance reviews and mission-based management.Students’ satisfaction with their educational experiencerose sharply from historical patterns, and reflectivenarratives describe significant changes in the workand learning environment.

CONCLUSIONS: This case study of emergent change ina medical school’s informal curriculum illustrates theefficacy of novel approaches to organizational develop-ment. Large-scale change can be promoted with anemergent, non-prescriptive strategy, an appreciativeperspective, and focused and sustained attention toeveryday relational patterns.

KEY WORDS: organizational culture change; learning environment;

informal curriculum; medical education; professional competence.

J Gen Intern Med 23(6):715–22

DOI: 10.1007/s11606-008-0543-y

© Society of General Internal Medicine 2008

INTRODUCTION

Calls for organizational culture change are resounding in a growingnumber of health care discourses. We are urged to improve the“informal curriculum” of medical education,1–3 create cultures ofpatient safety4 and customer service,5 and change the culture ofbiomedical research.6Understanding culture and culture change isbecoming a core competency for systems-based management andorganizational leadership in health care delivery and education.7

While “culture” in a deep sense may seem unapproachableand intractable, an organization’s culture is actually mani-fested and sustained as everyday patterns of human interac-tion, for example, how one behaves in a meeting, what can orcannot be talked about with those in authority, who makesdecisions, or how differences are handled.8 These patternsmay arise accidentally and later become taken for granted andself-sustaining through repetition. Motivated by the recogni-tion of suboptimal behavior patterns, typical culture changeinterventions, such as mandatory workshops or the imple-mentation of an organizational “values statement,” areplanned and introduced from the “top” down. They are basedon a hierarchical model of organization and assumptionsabout management control that are not well-suited to actualhuman interaction.9–10

In this report, we present 1 medical school’s experience witha new approach to culture change undertaken to better alignthe informal and formal curricula at Indiana University Schoolof Medicine. We describe the project’s methodology, illustrateits impact, and briefly explicate the underlying principles andcontemporary social science theories on which it was based.

CASE STUDY

The Setting

Indiana University School of Medicine (IUSM) is the second-largest U.S. allopathic medical school with approximately

Received August 28, 2007Revised January 14, 2008Accepted January 25, 2008Published online March 14, 2008

715

1,100 students, 1,200 full-time faculty, 1,000 residents andmany hundreds of administrative staff and other personnel.Students matriculate in the basic sciences curriculum for2 years at 1 of 9 campuses statewide. Their third and fourth-year clinical rotations take place primarily in Indianapolis at aVeterans Health Administration hospital, a public hospital, achildren’s hospital, a private voluntary hospital and a univer-sity hospital.

The Project Context

In 1999, after 8 years of curricular research and review, IUSMrestructured its formal curriculum and graduation require-ments around 9 competencies deemed essential to excellentmedical care (Table 1).11 Even as the competency curriculumwas being developed, its planners recognized that the goal ofgraduating knowledgeable, compassionate, and respectfulphysicians would be undermined if the faculty and staff didnot consistently embody and reinforce in their everydayconduct the moral, ethical, professional, and humane valuesarticulated in the formal curriculum—i.e., if the informal andformal curricula did not reinforce one another. Distressingly,quantitative and qualitative data from the American Associa-tion of Medical Colleges Graduation Questionnaire (GQ) hadbeen indicating that IUSM students were not experiencing acompassionate, respectful, and responsive learning environ-ment. Many students reported feelings of alienation, disre-spect, and a lack of attention to their concerns by theadministration.

Late in calendar year 2002, 2 new faculty with scholarlyinterests in professionalism and communications (TSI, RMF)received a 3-year grant from the Fetzer Institute to foster aculture of Relationship-Centered Care within the medicalschool. The term “Relationship-Centered Care” had beenintroduced by the Pew-Fetzer Task Force to call attention torespectful, collaborative relationships as a critical foundationfor humane and effective medical care: relationships betweenpatients and clinicians, among members of interdisciplinaryhealth care teams, between the health care system and thecommunity, and, underlying all these relationships, relation-ship with self.12 The IUSM project directors convened aSteering Team comprised of themselves, the Associate Deanfor Medical Education and Curricular Affairs (DKL), a ProjectManager (DLM), and two external consultants (ALS, PRW). TheIUSM Relationship-Centered Care Initiative (RCCI) waslaunched in January, 2003.

RCCI Guiding Principles and Rolling Process

The Steering Team envisioned its goal as fostering a morecaring, respectful, and collaborative culture throughout IUSM,enhancing the informal curriculum so it would more consis-tently embody and reinforce professional values. As weembarked on this initiative, three theoretical principles guidedour thinking and actions.

The first principle, employing emergent design, involvedpursuing change but letting the specific path of implementa-tion emerge through collaboration between project leaders andmembers of the organization. From the outset, we recognizedthat we could not prospectively design a 3-year program tochange the culture of IUSM. Rather, each action step woulddepend on what had happened during the preceding step, whohad been engaged and what new ideas and opportunities hademerged, none of which could be known or stipulated inadvance. In January of 2003, we planned only an initial stepwith the intention of discerning subsequent opportunities aswe proceeded.

A second guiding principle, choosing to recognize anddisseminate success, included the use of Appreciative Inquiry(AI), an organizational change methodology that focusesattention on the root causes of success within an organizationrather than on barriers and deficiencies.13,14 AI builds morecompetence, confidence, and hope and is thus more motivat-ing than traditional problem-focused approaches.

A third principle, adopting the theoretical framework ofComplex Responsive Processes of Relating, grounded our workin a complexity-inspired theory of human interaction, whichdescribes how large-scale patterns of interaction can bechanged by changing local, small-scale behaviors.8,15 Organi-zational culture is the aggregate of myriad small patterns,which persist only if they are reenacted in each new moment.The work of culture change is to call individuals’ attention tothe relational patterns being enacted in the moment, how theythemselves are contributing, and how they might participatedifferently to give rise to different, more desirable patterns.

We began our change initiative by recruiting a “DiscoveryTeam” (DT) to conduct appreciative interviews throughoutIUSM, gathering stories of moments when IUSM’s organiza-tional culture embodied exactly those standards of profession-alism that we want our students to learn. The DT, consistinginitially of 1 student, 1 resident, and 10 faculty, conducted andanalyzed 80 interviews, finding 4 overarching themes: thewonderment of medicine, the importance of connectedness,passion for one’s work, and believing in everyone’s capacity tolearn and grow.16 Three months into the project, the DTpresented these themes and stories at a public “Open Forum”,mirroring back to the institution its strengths and offeringaccounts of successful relationships as models for futurechange. Following this event, the Steering Team reflected onwhat had happened and identified several next steps, whichthen led to more next steps, setting in motion an unplannedbut hoped-for cascade of events and changes in organizationalculture.

Evaluation Methods

We decided a priori to treat our project as an organizationalcase study, evaluating the effect of our change process with amulti-method qualitative–quantitative design. First, we sought

Table 1. The Nine Competencies of the Indiana University School ofMedicine Curriculum

Competency

1. Effective Communication2. Basic Clinical Skills3. Using Science to Guide, Diagnosis, Management, Therapeutics,

and Prevention4. Lifelong Learning5. Self-Awareness, Self-Care, and Personal Growth6. The Social and Community Contexts of Health Care7. Moral Reasoning and Ethical Judgment8. Problem Solving9. Professionalism & Role Recognition

716 Cottingham et al.: Enhancing the Informal Curriculum at IUSM JGIM

to track events and new processes that emerged with clear andunambiguous ties to the RCCI. Two of us (TSI and DLM) kept arunning project journal (“Straws in the Wind”) capturing suchactivities, whether or not they were sustainable. Next, ourprimary prospective, non-vested qualitative approach was toengage an independent observer (DWB) who reported not tothe project team but to the Board of Directors of the FetzerInstitute. DWB made monthly visits from March 2004 onwardto interview students, faculty, and leaders and to observe RCCIactivities. After more than 2 years of activity, he prepared areport to the Fetzer Institute based on his IUSM key-informantinterviews and his participant-observer field notes. A second-ary prospective qualitative strategy was to harvest contentfrom minutes taken at project meetings and from the con-sultants’ field notes. A fourth strategy that emerged 4 monthsinto the project was to invite participants at each DiscoveryTeam meeting to describe “changes in patterns of relating” theyhad either observed or attempted. These observations,recorded in the minutes, were later reviewed and categorizedby the authors in preparation for this report using an in-teractive consensus-building content coding process. In thisreview, we specifically sought to identify all negative commentsand outcomes in these sources, reviewing all the above-namedsources and content froma 2007 IUSMsurvey of “faculty vitality”.

The primary prospective quantitative strategy was to trackchanges on selected items in students’ responses to the GQsurvey. A secondary prospectively identified quantitative eval-uation was tracking the number of people engaged in theproject and their positions in IUSM as an indicator of theproject’s engagement with the academic community. Relativelylate in the project, we began to track applications to IUSMwhen members of the Admissions Committee who had imple-mented RCCI-inspired changes in committee process noticedchanges in the patterns of IUSM applications and brought thisindicator measure to the attention of the Steering Team.

Evidence of RCCI Impact

Five lines of evidence demonstrate the still-evolving impact ofthe RCCI change process. First, following the DT interviews,IUSM community members and project staff initiated a varietyof new RCCI activities, none of which could have beenanticipated at the outset of the initiative.

Student Appreciative Inquiry Interviews. Inspired by the DTInterviews, several IUSM students decided to visit each of our 9campuses, introducing the theories and goals of the RCCI tomore than 130 students. They also interviewed 80 classmatesabout high-point experiences of professionalism, publishing apocket-sized volume of narratives17 that was presented to eachentering student at the 2004 IUSM White Coat ceremony. Twosimilar volumes have been created by subsequent cohorts ofstudents, sustaining the flow of IUSM narrative.18,19

Admissions Committee. After learning of the RCCI and the DTstories, the Admissions Committee chair recognized theimportant contribution of the admissions process and criteriato the school’s culture. Her committee subsequently re-designed the entire admissions process to recruit and selectstudents with a strong relational orientation. Committeemembers designed, learned and practiced new admissions

interview techniques that embodied IUSM formally espousedcompetencies with the help of “standardized applicants.”

Executive Coaching. Shortly after the first Open Forum, theDean and Executive Associate Deans requested monthlymeetings with the external consultants to reflect on how theiractions affected the organizational culture. Together theydevised relationship-centered approaches to such executiveactions as department chair evaluations, layoffs, and theimplementation of mission-based management.

Other Coaching. The external consultants also met with othermedical school leaders (including department chairs,committee chairs, and residency directors) and more than 30groups (including departments, committees, offices, clinicalteams, alumni, and community physicians) to apprise them ofthe RCCI and the DT interview findings and to elicit theirsuggestions for and participation in further activities. At somecommittee meetings (e.g., the Curriculum Steering, AcademicStandards, and Teacher-Learner Advocacy Committees) theyinvited committee members to reflect on the relational aspectsand consequences of their meeting practices and committeebehavior. These conversations often prompted specific newpolicies and procedures, for instance suspending the use of animpersonal form letter (called the “ding” letter) to informfaculty of poor student ratings of their courses or rotations.

Change-agent Development. Immediately after the first OpenForum, a dozen new volunteers joined the Discovery Team,which evolved into a learning community for internal changeagents, meeting monthly for coaching and support. When DTmembers requested additional training, the external con-sultants organized a year-long program called “The Courageto Lead” consisting of four 1.5-day sessions. Modeled onParker Palmer’s teacher formation program,20 this programfosters self knowledge, authentic presence, and healthyrelationships. It helps participants step outside of usualsocial patterns at IUSM to, in the words of Mahatma Gandhi,“be the change you want to see in the world.” Two IUSM facultymembers (DKL, RMF) assumed facilitation responsibilitiesafter receiving external training and on-site mentoring forthis role. Over 50 individuals have participated in the first 3cycles of this ongoing program. In addition, 30 members of thecampus community, nominated for their high-potential aschange agents, enrolled in a 5-session, 18-hour InternalChange Agent Program that focused on organizational changetheories, facilitation skills, and personal awareness and offeredcoaching and support for change initiatives in the participants’local work environments.

Non-starter and Unsustainable Activities. As might be expectedin any evolving, emergent-design initiative, some new venturesdid not spread everywhere, and some interventions were notsustainable. Two attempts to spark academic department-based versions of the larger RCCI did not gather sufficientmomentum or commitment to become self-sustaining. Effortsto engage residents and residency programs lagged behindefforts to engage medical students and the undergraduateprogram. Some initially robust activities ran their course anddissipated over time, including the Discovery Team itself. In

717Cottingham et al.: Enhancing the Informal Curriculum at IUSMJGIM

their place, other RCCI projects have emerged (e.g., projects onprofessionalism and fostering humanism in health care) thatbroadened the scope of the initiative to include more inter-professional health care providers and clinical microsystems.

The second line of evidence for RCCI impact is derived fromthe June 2006 report of the external evaluator who stated:

Of note...are the many ways in which RCCI hasaffected the way in which IUSM conducts its dailywork. A general acceptance of the value of relation-ship and of ‘relatedness’ appears to have permeatedthe administrative infrastructure of the school.21

Baldwin and the external RCCI consultants also cite keyinformants’ specific observations of culture change at IUSMthat illustrate positive elements or trends of organizationaltransformation (Table 2).

The third line of evidence for RCCI impact derives from ananalysis of participants’ observations during the monthly DTmeetings. Table 3 shows representative descriptions ofchanges attributed to the RCCI. These comments clusteraround 3 themes:

& New meeting formats and practices. IUSM faculty and staffhave introduced new practices into standing meetings,teaching conferences, and other activities to make theseevents more relational and collaborative. The appreciativepractice of sharing success stories has spread widely inboth administrative and educational contexts.

& New institutional procedures and programs. These rangefrom faculty development programs for new hires to newstudent leadership positions.

& Communication about culture. Faculty, residents and stu-dents have created new communications vehicles that raiseawareness of the changing IUSMculture, including anRCCInewsletter, monthly informational emails, and others.

It is noteworthy that in all sources of archival informationreviewed for this report, negative comments about the RCCIwere far fewer in number than positive ones. Rather thancynical or dismissive statements about the RCCI, the availablerecords captured only ‘negative comments’ that seem torepresent certain individuals’ initial concerns or healthyskepticism (Table 4):

& Initial skepticism regarding the RCCI likelihood of success.An early area of concern regarding the RCCI was whether aculture change strategy focused on improving professionalrelationships and relying on an emergent process ofdiffusion, could succeed. Several individuals closely relatedto the RCCI expressed doubts. However, these doubts werereplaced by support for the project as the change processunfolded over time.

& Skepticism regarding the personal impact of RCCI activities.Participants in RCCI activities were sometimes uncomfort-able initially with the nature of those activities, particularlythose involving reflection and self-disclosure. In 3 years ofdata collection we found only 1 comment from a partici-pant who felt there was no value to an RCCI activity. Mostpeople became comfortable with personal sharing overtime, often finding it to be personally transformative.

& Skepticism regarding RCCI methods. The nature of theRCCI’s emergent design strategy was unfamiliar and dis-

Table 2. A Sample of Observations on Noteworthy OrganizationalChange at IUSM Recorded by the External Evaluator and External

Consultants, Grouped by Source

Observations

IUSM Dean and Executive Associate Deans• “RCCI offers a way of engaging people in values-based discussions.”• “Crucial enabler, providing a framework and a methodology for setting

up and facilitating the conversations that have had and are havingsuch a broad impact on the school.”

• “We are infecting people, one at a time. There’s a significant changefrom two years ago. People are talking and behaving differently.”

• “Values and professionalism are percolating through the institution.”• “I observed an enthusiasm from those involved in RCCI. I wanted to get

more involved in this process so I could better understand and wouldthus be able to articulate what RCCI was doing for the School.”

• “The RCCI has helped me to be a more caring and thoughtful individualin the way I deal with other people than I otherwise would have beenduring this time.”

• “Our level of professionalism is substantially higher—what we expectfrom each other and from ourselves, especially in our relationshipswithstudents. I’d like to think that professionalism in our relationships withpatients has been there all along, but our relationships with studentsand with each other have changed. We show more respect for eachother; we value each other and aremore sensitive to each other’s needs.These newer behaviors are becoming an expected norm.”

• “The practice plan is operatingmore like a group now. People are startingto think about the whole institution, instead of just their part.”

• “I think my conversations with faculty are a little bit different. I go intothem now having consciously decided not to have preformed opinions.I’m more of an active listener.”

• “The previous sense of cynicism towards high-minded ideals is gone.Behaviors that are detrimental to relationships are much less evidentthan they were before at a faculty level. Expressions of anger anddisrespect are less acceptable parts of our culture.”

IUSM Committee Members• “We feel we are changing the nature of our conversations.”• “We are asking how we can do this better.”• “We are learning to check in, to learn from each other.”• “Reframe from the usual crime and punishment scene to one of being

more present, more respectful.”• “Humanizing the experience...Rules without relationship create

resentment.”Faculty at Large• “It’s a wonderful idea and program, taking on organizational and cultural

change in such a large and complex organization. Having been at someof the meetings, the thing I’ve been most impressed about is how theinitiative has accomplished one of its goals, achieving effects at twolevels, from the top down and bottom up. The effect as shown in thestudents’ stories [in an online journal] has been amazing, and frombeing at meetings with the Deans, to have gotten their complete buy-inand support is nothing short of a huge success.”

Residents• “At the Discovery Team meetings there were...all the “relational tools”

people brought in—ways of seeing things, understanding a differentpoint of view, that I learned from. I’m trying to incorporate these into myways of doing things and it has broadened my skills considerably.”

• “I did notice that I said something to a resident recently and they said“Oooh, I like the words you used”, and it was something someone saidduring the coaching sessions and I thought, “Maybe I AM learningsomething.”

• “Quite a bit of effort was placed in including people from all levels ofthe school.”

Medical Students• “Before becoming aware of theRCCI, I’d look at things in the school andpick

out all the bad things. I’d say, ‘I don’t like doing this exercise, I don’t getanything out of it and I don’t understand why I have to do it.’ Now I realizethatmycomplainingdoesnogood. In general, I try to focusonmorepositivethings. For example, I just had very positive autopsy exercise yesterday, sowhen I go to school today, I’ll tell my friends how great it was—it was noteasy and it took a long time, but it’swhatmedicine is all about. So they’ll goin with a good attitude. That’s part of continuing the dialogue.”

• Clinic was “different from usual. The attending is spending more timeand being more interested in me and the patient.”


concerting to some. People were encouraged to embodyand enact a new way of being in their work environments,drawing on their own self-knowledge and vision of animproved, relational organizational culture, but no blue-prints for specific action were provided. Over time, asindividuals began to request personal coaching, facultydevelopment, and personal formation programs, much ofthe confusion of the first year of the initiative diminished.

& Skepticism regarding the ability of the RCCI to transform allaspects of IUSM culture. As participants embraced a focuson relationship and worked to encourage improved rela-tionships in their professional lives, they noted that someenvironments seemed less amenable to culture changethan others. We attempted to identify and work in areas ofreadiness, recognizing that if a critical mass emerged insome microsystems, change was likely to diffuse to otherareas in time.22

A fourth convergent line of evidence suggesting that theRCCI has had an impact at IUSM is the growth in participationin RCCI over time. From early 2003 to the end of calendar year2005, the number of participants in RCCI activities grew fromthe 6 initial team members to more than 900 faculty, students,residents, staff, allied health professionals and patients.Participation rates have been particularly high among mem-bers and leaders of IUSM’s standing committees, involving33% of all committee members and 52% of the most activelyengaged faculty members (those serving on 2 or more commit-tees). For the 10 committees concerned with education andstudent life, 90% of the chairs and 71% of the members haveparticipated.

The fifth line of evidence for the RCCI’s impact comes fromthe IUSM Graduation Questionnaire data. Starting in 2004,responses to the item on the AAMC GQ assessing students’overall satisfaction with their medical education rose sharplyfrom low baseline annual assessments to annual reports abovethe national average—a level of performance historicallyunprecedented at IUSM (Fig. 1). Scores assessing studentsatisfaction with the administration also rose significantly(Fig. 2). Trends in medical school applications offer additionalsupporting evidence. Medical school applications generallyrose nationally after 2003, but IUSM has seen a morepronounced rise in out-of-state and in-state applications thanits peers (Fig. 3). While we would not attribute this overalldoubling in applications solely to the RCCI, our AdmissionsCommittee and Executive Associate Dean for Educationprominently cited the RCCI and the competency curriculumas the 2 key contributors to this remarkable growth.23,24

DISCUSSION

This case study demonstrates that culture change is possiblein a large public school of medicine. Specifically, it shows howa medical school community fostered a relational environmentthat more closely reflects the values of its competency-basedcurriculum. Employing a strategy of “emergent design,” westarted with a modest intervention to prompt reflection oneveryday interactions, then traced and supported the subse-quent “ripples of change” that engaged the interest and energyof individuals throughout the IUSM community.

The RCCI began with an Appreciative Inquiry that calledattention to exemplary professional behavior. In response,individuals and committees became more mindful and inten-tional about their behavior and discovered that sometimes theywere unwittingly enacting values and modeling behaviors theydid not want to pass on to students. Many new patterns (e.g.,“check-in” at the start of meetings or routinely telling successstories) spread rapidly through the organization. These manysmall changes appear to be contributing to a change in the

Table 3. Illustrative Examples of Changes at IUSM Observed byMembers of the RCCI Steering and Discovery Teams and Attributed

(at least in part) to the RCCI

Observed Changes

New Meeting Formats and Practices• New meeting practices to “humanize” meetings of the standing

committees of IUSM (e.g., checking-in, noticing successes andappreciative debriefings) are spreading.

• The use of paired interviewing, reflective narratives and appreciativeinquiry is spreading (e.g., chief resident orientation, residentworkshops on professionalism, and elements of new NIH-fundedBehavioral and Social Sciences Integrated Curriculum.

• Staff members in the Office of Medical Education and Curricular Affairscreated and implemented a plan to be mindful of every personalinteraction and to manifest a relationship-centered culture in all oftheir work.

• The competency directors and coordinators transformed themselvesinto a “relationship-centered learning community” seeking to live thevalues of the competency curriculum as a way of disseminating themacross the school and the state.

• Methods from the RCCI are now being adapted to quality and serviceimprovement initiatives in facilities across the health system.

New Institutional Procedures and Programs• The Dean includes rigorous data on the work environment in

performance reviews for department chairs and conducts thesereviews in a relationship-centered manner.

• A major school-wide initiative in mission-based management wasdesigned and implemented with the explicit intention of fosteringpartnership, engagement, shared decision-making and trust.

• The Admissions Committee developed new criteria and newinterviewing methods to select relationally oriented applicants.

• The Academic Standards Committee changed its approach to reportingand addressing poor ratings on student course evaluations from aform letter (known as the “ding letter”) to a more personal andcollaborative conversation.

• A fifty-hour career development course has been created for newlyhired faculty that incorporates relationship-centered principles andemphasizes the importance of mentorship.

• Two leadership development programs (a year-long series of quarterlyretreats called The Courage to Lead and a 15 hour Internal ChangeAgent Program) have been added to the roster of faculty developmentactivities. Originally conducted by the external consultants, theseare now internally planned and facilitated.

• Students requested and received approval for a permanent Dean-appointed student leadership position intended to promote the RCCIand to foster mindfulness of relationship in campus activities.

• After protesting reduced library hours, students responded suc-cessfully to an invitation to develop an alternative plan that metnecessary financial constraints.

Communication about Culture• The School’s weekly newsletter, Scope, now includes a column entitled

“Mindfulness inMedicine” that uses stories of actual faculty and traineeexperiences to focus attention on relationships and professionalism.

• Students created a special Bulletin Board in the student center devotedto promoting student interest in the activities and events of the RCCI.

• A group of students published a book of students’ stories aboutprofessionalism that was presented to incoming students at theWhite Coat Ceremony. In each of the subsequent two years,students created and published similar books presenting art,stories, and poems by IUSM faculty, residents, and studentsreflecting human- istic aspects of doctoring.


overall experience of working and learning at IUSM. After3 years, changeswere evident in such core institutional practicesand procedures as the conduct of meetings, performancereviews, medical student selection, and staff communications.Students’ overall satisfaction with their educational experienceclimbed dramatically, and a wide variety of individuals noticedpositive changes in their work and learning environments.

The news that the informal curriculum can be intentionallychanged will be welcomed by medical educators whose care-fully designed programs on professional values are sometimesundermined by unprofessional behavior elsewhere in theirorganizations. But this case is also of wider interest. It illus-trates important, seemingly paradoxical, and non-traditionalprinciples of organizational culture change that could beapplied widely.

The emergent design principle acknowledges that it is notpossible to predict or control the path by which new patterns ofbehavior will spread through an organization. An organizationis not a machine that can be designed, but rather a dynamicweb of conversations within which patterns of meaning (knowl-edge) and patterns of relating (culture) evolve over time througha non-linear, self-organizing process. These patterns can beinfluenced, but they cannot be programmed or controlled.8,15

As we began our initiative, we could not know whichcommittees or processes were ripe for change or which peoplewere ready to engage. Rather than targeting specific commit-tees and individuals of our choosing, we created a process bywhich they could identify themselves. We avoided the ill willand wasted effort engendered by forcing change on people whoare not ready for it. Instead, we found people who were

Table 4. Negative Comments about RCCI Organizational Change at IUSM Taken from Steering and Discovery Team Minutes, PersonalInterviews, Formal Reports, and Articles, Grouped By Theme

Comments

Initial Skepticism Regarding the RCCI Likelihood of Success• “When initially briefed on RCCI, my first reflex was that this was too “warm and fuzzy” and that people would trivialize it no matter how well-

intentioned the program. ...To my surprise, we experienced an outpouring of truly remarkable stories that created a groundswell of pride andinspiration among participants.”IUSM DeanAcademic Medicine, 2007; 82:1094–1097

• “What I honestly thought might be a “noble failure” when I accepted this assignment, has amazed me with its power and, yes, its unique form of rigor.It has truly engendered the hope that this “experiment” might lead to long needed changes in medical education and patient care.RCCI External Evaluator2004 Report to the Fetzer Institute

• Trusting others did not become my strong suit. At the outset of the Relationship-Centered Care Initiative, I was solidly in this career-long orientation..... To my surprise, people in high-risk environments were just as likely to take positive steps as others, perhaps because the felt need resided there.

In spite of being one of the principal leaders for RCCI, the weight of responsibility for designing project plans and was not upon my shoulders. I wouldtake my initiatives within my own environment but expect that institutional ‘emergence’ would serve as the optimal intelligence for program activitiesinstitution-wide.President and CEO, Regenstrief InstituteInterview with RCCI external consultants, 2006

Skepticism Regarding the Personal Impact of RCCI Activities• I participated in the RCCI when I could, but got nothing out of it.IUSM FacultyResponse to RCCI survey on faculty vitality, 2007

• When I was asked to participate in the RCCI Courage to Lead program, I was totally unaware of what the program was about and what it entailed. Thefirst session was very difficult for me to find a comfort level in the group. I had never participated in such a discussion group with people I barelyknew and some I didn’t know. As the year progressed, I realized that I was looking forward to the retreats and found it much easier to express myselfand join in the group. I found the sessions ... helped me to reflect on my feelings and look at how I was not attending to my own needs. ... I willalways remember the sessions and continue to try and incorporate the ideas of the sessions in my life and career.

Clinician, Co-Chair of key IUSM administrative committeeResponse to RCCI survey on faculty vitality, 2007

Skepticism Regarding the Methods of the RCCI• At each [Discovery Team] meeting the consultants asked us what changes we were noticing in the IUSM culture, and what we were trying. I wasn’t

sure that any positive elements of the IUSM culture that I was noticing were the direct results of the RCCI, or just my decision to consciously attendto the positive. I was also not sure what new “things” I should be trying. I had always tried to be friendly and helpful to my colleagues, but I knewthis wasn’t enough. What else was I supposed to be doing?

Medical Education Staff, currently a core member of the RCCI Leadership TeamFrom written description of experience with the RCCI, 2006

Skepticism Regarding Ability of the RCCI to Transform All Aspects of IUSM Culture• Recorded in the Discovery Team minutes, 2005:Another DT member expressed appreciation for the DT environment but is feeling unsuccessful helping it to spread elsewhere. There is not awidespread perception that communication and relationship are important. The working environment seems to be better in community hospitalsthan academic ones, but there’s less teaching taking place in those settings. It’s validating to see others who care about this.

• Recorded in the Discovery Team minutes, 2006:Two DT members shared some frustration with their inability to fully engage physicians (most notably more experienced staff physicians) in theirrecent departmental and organizational change efforts. Potential reasons for a lack of engagement include time constraints, a lack of highlyscientific quantitative evidence regarding potential benefits to patients and a lack of understanding of how this approach might benefit theirpractice. The group discussed ...potential approaches.


attracted to the vision and encouraged their initiatives—activities which then attracted more people, growing a criticalmass. Not everything that was ventured prospered. In fosteringorganizational change, false starts and dead-ends are to beexpected, not-knowing is normal (even virtuous), and successdepends on persistence and ongoing reflective discernment.

The second principle, grounded in the organizational methodof Appreciative Inquiry, is to change what is not working in anorganization by paying more attention to what does work.13,14

Conventional problem solving seeks to identify and eliminatethe root causes of undesirable outcomes. Its focus on deficien-

cies often elicits anxiety, shame, and defensiveness, all of whichimpede behavior change.25 Instead, we called attention toexisting competence and capacity at IUSM. This enhanced theorganization’s self-image, bolstered confidence, and created ahopeful and self-fulfilling expectation that positive change wasindeed possible.

The third principle, approaching large-scale organizationalchange by focusing on everyday behaviors, expresses themajor insights of complexity theory.8,15 A hallmark of non-linear dynamics (complexity) is that small disturbances inpatterns—such as small changes in the conduct of a meetingor the sharing of information—can amplify and spread sponta-neously and unpredictably, sometimes resulting in transforma-tive change of the kind that seems to have occurred at IUSM.

Like all organizational case studies, this study has a numberof limitations. First, because there were many contemporane-ous initiatives and changing circumstances at IUSM (e.g., theevolution of leadership, the contributions of the RCCI, matura-tion of the competency curriculum), it is obviously inappropri-ate to attribute changes in our culture to any single factor.Instead, like ecologists tracking change in an environmentalniche, we sought to use indicator measures and to invokemultiple lines of evidence to describe and triangulate changewhile remaining cautious about isolated cause-and-effect infer-ences. Second, participant observation data are subject to thebiases (perspectives) of the observers. Some of our key observ-ers were more than just participants in the RCCI process, theywere initiative leaders and could have been more likely to noticechanges and ascribe them to the initiative. For that reason, inthis report we have attempted to use “peer checks” from ourexternal evaluator and tracking measures derived from rou-tinely collected student reports to triangulate and balanceparticipant–observer data. Third, every institution is unique inits history, structure, and the composition of its academicmedical center community. The outcomes of a culture-changeinitiative in our setting are of unknown generalizability.

These cautionary notes not withstanding, we believe that aculture-change initiative at 1 medical school succeeded inengaging many faculty and organizational leaders within theschool, stimulated a remarkable efflorescence of activities that

Figure 3. Percentage change in Indiana University School ofMedicine (IUSM) applications from Indiana residents and out-of-state applicants compared to all US medical schools. The Rela-tionship-Centered Care Initiative at IUSM began in the middle of

the 2002–2003 academic year.Figure 1. Trends in Indiana University School of Medicine (IUSM)and national student responses to the American Association ofMedical Colleges Graduate Questionnaire item # 14: “Indicatewhether you agree or disagree with the following statement:

Overall, I am satisfied with the quality of my medical education.”The Relationship-Centered Care Initiative at IUSM began in the

middle of the 2002–2003 academic year.

Figure 2. Trends in Indiana University School of Medicine (IUSM)and national student responses to the American Association ofMedical Colleges Graduate Questionnaire item # 18: “Indicateyour level of satisfaction with the following: Responsiveness ofadministration to student problems.” The Relationship-CenteredCare Initiative at IUSM began in the middle of the 2002–2003

academic year.


enhanced its environment, and exerted a favorable impact on avariety of organizational performance indicators—includingadmissions, student perceptions of school’s responsiveness,and their perceptions of the overall quality of their education.In our setting, it was reinvigorating to stop “just talking” aboutthe hidden curriculum and, instead, to try to do something toimprove it. Like others, we found that culture change is anunpredictable non-linear process that is not amenable tolinear, top–down approaches. We were able to foster large-scale organizational change with a flexible, emergent, and non-prescriptive strategy; an appreciative perspective; and focusedand sustained attention to everyday relational patterns.

Acknowledgments: The authors wish to acknowledge the editorsand reviewers of JGIM for helping us improve the clarity of thepresentation.

Conflict of Interest Statement: The authors have the followingrelationships with for-profit institutions: Ann H. Cottingham, MAR,none; Anthony L. Suchman, MD, MA, paid consultant to theRelationship-Centered Care Initiative; Debra K. Litzelman, MA, MD,none; Richard M. Frankel, PhD, grant received from the ZimmerCorporation; David L. Mossbarger, MBA, none; Penelope R. Williamson,ScD, paid consultant to the Relationship-Centered Care Initiative; DeWittC. Baldwin Jr., MD, none; Thomas S. Inui, ScM, MD; grant received fromthe Zimmer Corporation.

Corresponding Author: Ann H. Cottingham, MAR; Medical Educa-tion and Curricular Affairs, Indiana University School of Medicine,714 N. Senate Ave., EF-200, Indianapolis, IN 46202-3297, USA(e-mail: [email protected]).

REFERENCES1. Hafferty F. Beyond curriculum reform: confronting medicine’s hidden

curriculum. Acad Med. 1998;73:403–7.2. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine.

Washington, DC: Association of American Medical Colleges; 2003.3. Stern DT, Papadakis M. The developing physician—becoming a profes-

sional. N Engl J Med. 2006;355:1794–9.

4. Leape LL, Berwick DM. Safe health care: are we up to it? We have to be.BMJ. 2000;320:725–6.

5. Oswald WW. Creating a service culture. Healthc Exec. 1998;13(3):64–5.6. Zerhouni EA. Translational and clinical science—time for a new vision.

N Engl J Med. 2005;353:1621–3.7. Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S. General

competencies and accreditation in graduate medical education. HealthAff. 2002;21(5):103–11.

8. Suchman AL. A new theoretical foundation for relationship-centeredcare. J Gen Intern Med. 2006;21:S40–4.

9. Stacey RD. Strategic Management and Organisational Dynamics. 3rdednHarlow, England: Financial Times Prentice Hall; 2000.

10. Streatfield PJ. The Paradox of Control in Organisations. London:Routledge; 2001.

11. Indiana University School of Medicine. The Indiana initiative: Physiciansfor the 21st century. Indianapolis: Indiana University School of Medicine;1996.

12. Tresolini CP, and the Pew-Fetzer Task Force. Health ProfessionsEducation and Relationship-centered Care. San Francisco, CA: PewHealth Professions Commission; 1994.

13. Watkins JM, Mohr BJ. Appreciative inquiry: Change at the Speed ofImagination. San Francisco, CA: Jossey-Bass/Pfeiffer; 2001.

14. Cooperrider DL, Srivasta S. Appreciative inquiry in organizational life.Res Organ Change Dev. 1987;1:129–69.

15. Stacey RD. Complex Responsive Processes in Organizations. London:Routledge; 2001.

16. Suchman AL, Williamson P, Litzelman DL, et al. Towards an informalcurriculum that teaches professionalism: transforming the social envi-ronment of a medical school. J Gen Int Med. 2004;19:501–4.

17. Taking Root and Growing: Becoming a Physician at Indiana UniversitySchool of Medicine. Indianapolis: Indiana University School of Medicine;2004.

18. Reflecting Caring Attitudes through Action. Indianapolis: Indiana Uni-versity School of Medicine; 2006.

19. Helping Hands: Reflections on Humanities in Medicine. Indianapolis,Indiana University School of Medicine; 2007.

20. Palmer PJ. The Courage to Teach: Exploring the Inner Landscape of aTeacher’s Life. 1stSan Francisco: Jossey-Bass; 1998.

21. Baldwin DC. Evaluation Report to the President and Board of Trustees ofthe Fetzer Institute. June 30, 2006.

22. Rogers E. Diffusion of innovation. Fifth EdNew York, NY: Free Press;2003.

23. Litzelman DK, Cottingham AH. The new formal competency-basedcurriculum and informal curriculum at Indiana University School ofMedicine: overview and five-year analysis. Acad.Med. 2007;82:410–21.

24. Brater DC. Infusing professionalism into a school of medicine: perspec-tives from the Dean. Acad Med. 2007;82:1094–7.

25. Deming WE. Out of the Crisis. Cambridge, MA: Massachusetts Instituteof Technology, Center for Advanced Engineering Study; 1986.


PREPRINT: Accepted for publication in Medical Care in 2010. Please check with me before copying, distributing or citing this work. Thank you!

Organizations as Machines, Organizations as Conversations:

Two Core Metaphors and their Consequences

Anthony L. Suchman, MD, MA

Relationship Centered Health Care

University of Rochester School of Medicine and Dentistry

Rochester, NY

Corresponding author and address for reprints:

Anthony L. Suchman, MD

42 Audubon St.

Rochester, NY 14610

Fax: 206-350-7113

Phone: 585-271-4233

Email: [email protected]

Running head: Core Metaphors for Organizations

Word count: 3990

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Abstract

One factor contributing to the limited success of organizational change initiatives is the use of an outmoded conceptual model: the organization as machine. This metaphor leads to the creation of detailed blueprints for desired changes; invitesunrealistic expectations of control; and creates anxiety, blame and defensiveness when events inevitably don’t proceed according to plan, thus hindering the work.

An alternative conceptualization – the organization as conversation – portrays an organization not as a reified object upon which we can act but as self-organizing patterns of thinking (organizational identity and knowledge) and relating (organizational culture)that exist in the medium of human interaction in which we participate.

Principles of complexity dynamics (self-organization) have important implications for organizational change practices. (1) Organizational change requires mindful participation – reflecting on and talking about what we are doing together here and now, what patterns of thinking and interacting we are enacting and what new behaviors might interrupt old patterns or give rise to new ones. (2) Diversity and responsiveness favor the emergence of novel patterns. Skilled facilitation can enhance these characteristics when novelty is desirable; checklists and protocols can diminish these characteristics when consistency and reliability are needed. (3) We can’t know in advance the outcomes of our actions so we need to hold plans lightly, value “not knowing” and practice emergent design.

The organization-as-conversation perspective also has important implications for T3 translational research, redefining its purpose, suggesting new methodologies and requiring new approaches for evaluating proposed and completed projects.

Keywords: organizational change, organizational improvement; administration; management; complexity; health services research; quality improvement; hospital administration.

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Introduction

In 2002, my consulting partner and I received a call from the Indiana University School of Medicine (IUSM) seeking help changing the school’s culture so the day to day interactions among students, faculty and staff (the “informal curriculum”(1)) would reinforce rather than undermine the values of the school’s formal competency-based curriculum.(2)

Our first reaction was delight. As long-time advocates of incorporatingcommunication and relationship skills as core components of medical education, we had dreamed of such an opportunity – a school-wide focus on relationship-centered care.

Closely following our first reaction was a second one – panic! IUSM is the second largest medical school in the United States – 1100 medical students, 1200 faculty, 9 campuses around the state, thousands of staff members. How could we possibly createchange on such a large scale? Here we were, offered the chance of a lifetime, with no idea how to plan and implement such a huge change project.

Change leadership is becoming a core competency for healthcare managers and executives. Healthcare organizations face unprecedented demands for major change in many quarters simultaneously: improving quality and safety; enhancing the patient’s experience of care; embracing new roles for patients, family members and professionals;responding to new publicly reported performance measures and financial incentives; and others. The limited success (3) and widespread cynicism (4) associated with change initiatives suggest that we still have much to learn about this process.

One improvement opportunity is to change the conceptual model that guides most change projects. Working with many healthcare leaders, I have observed that notwithstanding recent developments in the field, (5-7) the prevailing view of organizations is still that of the organization-as-machine, a control-oriented manager-centered approach dating back to Frederick Taylor more than a century ago.(8) In this paper we’ll explore how inadequate this mechanical model is for what is a fundamentally social process; it can actually impede change. We’ll then consider an alternative conceptualization – the organization-as-conversation – that is less structural and more dynamic, focusing attention on how ideas and relationships form, propagate and evolve in the medium of human interaction. This model leads to very different actions and expectations on the part of change agents, ones more conducive to success.

Organizations as MachinesThe machine metaphor is ubiquitous. We can hear it in everyday speech: “things

are humming,” “well-oiled,” “on autopilot,” “firing on all cylinders,” “re-engineering,” and “I’m just a cog in the wheel.” Viewing an organization as a machine shapes our perceptions, expectations and actions profoundly. We can design and operate machinesto do exactly what we want. Each part has a precise function which it carries out repetitively and without variation resulting in reliable overall performance. To modify a machine’s function, we make a new blueprint and build exactly according to specification. The machine doesn’t participate; change comes only from the engineers

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who expect and are expected to be in complete control of the design, implementation, and results. Unexpected results imply culpability for deficiencies in design or execution.

This is a problematic way to view organizations, comprised as they are of people. Unlike machine parts, people think about their work. Repetition breeds boredom; we’re curious, stimulated by novelty, always tinkering. Managers working as engineers don’t notice this vast creative capacity of their “machine” or harness its ever presentspontaneous experimentation. We dislike being told what to do, preferring to work moreautonomously (9) and we tend to avoid change because it is often associated withuncomfortable emotional responses such as fear and grief.(10) The machine model doesn’t address these important phenomena..

Most problematic are the unrealistic expectations of control. Organizational work is inevitably uncertain and unpredictable, yet not knowing what to do is seen as a deficiency, giving rise to anxiety. When things don’t go as planned, there is an implicit assumption that someone screwed up. Our efforts to avoid blame and preserve self-esteem divert considerable energy and attention from the work itself.

Organizations as ConversationsAn alternative perspective shows us an organization not as a reified object,

separate from us, that we can manipulate and control, but as a set of ongoing interactions – a conversation – of which we are an inseparable part. Not just a metaphor, this is literally true.(11,12) Think of how an organization comes to be. Someone envisions an undertaking she cannot accomplish alone. As she starts talking with others a shared notion of collective action begins to form. When this shared notion gains sufficient coherence and commitment, people begin to act in concert and the organization starts to function. The conversation spawns work processes, physical facilities, organizational charts, budgets, and all the other trappings of an organization. As the conversation changes buildings are torn down or new ones are built; budgets and organizational charts change; people are hired or laid off; products come and go; work processes change. The conversation precedes and gives rise to everything.

The organizational conversation includes everyone who is aware of, involved with or affected by the organization: workers, managers, leaders, customers (actual and potential), payers, regulators, competitors, and neighbors. It includes myriad sub-conversations that vary in such characteristics as numbers of participants, duration (from longstanding to one-time events), formality and legitimacy (from officially scheduled meetings to water-cooler gossip), influence (the likelihood that it will affect the net activity of the organization) and the medium of communication (e.g. spoken words, memos, legal documents, procedure manuals, human resource policies, board resolutions, and symbolic gestures).

We approach the work of organizational change differently when we view organizations as conversations rather than machines. We change a conversation not bycreating a new blueprint but by changing the way we participate and encouraging others to do likewise. We pay attention to the quality of the conversation, believing that the best path to a good outcome is good process. Accordingly, the core value is not to be in control but to be in right relation.(13) Without unrealistic expectations of control, there is less anxiety and defensiveness opening more space for curiosity, experimentation, dialog

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and critical reflection – ideal circumstances, as we shall see, for adaptability and innovation.

Self-organizing Patterns in ConversationsWithin organizational conversations there are two kinds of patterns: patterns of

meaning and patterns of relating (this is, of course, an oversimplification but helpful for clarity). Patterns of meaning (what people are saying and thinking) include organizational identity (purpose, mission, vision, values), knowledge (intellectual capital, how to organize and carry out the work), and strategy (current thinking about the future and what to do now to prepare for it). Patterns of relating (how people are interacting) constitute the organization’s culture – for example, how people treat each other, how they talk and dress, what can or cannot be discussed openly, who makes which decisions, and the whole panoply of power relations.

Patterns of meaning and relating in a conversation are continuously under construction; they must be re-enacted in each new moment or they will cease to be patterns, just as musicians in a performance must keep on playing new notes or the piece comes to an end. If we describe an organization’s culture as hostile, or as collaborative, that means that people keep on acting in a hostile or collaborative fashion time after time. While the patterns of any given moment tend to repeat and carry forward the patterns from the moment before, this is not inevitable. A new pattern can be enacted at any time; each new moment holds the potential for change.

The patterns of meaning and relating in a conversation can emerge without anyone’s intention, direction or control; they are self-organizing.(14) (Self-organization can occur when two or more entities simultaneously influence and are influenced by each other in the course of ongoing back and forth interaction.) Self-organization can yieldboth stable and novel patterns. As an example of stability, think of a time when you joined a new group – perhaps your first day at a new job, on a new committee or in a new class. You probably attended closely to how the other people were acting so you would know how to fit in. Our neurobiology demands this of us: attachment is an important regulator of the opioid levels in the brain.(15) Being excluded from the group would produce the endogenous equivalent of opiate withdrawal – a discomforting state we seek to avoid – so we act like the others to be included. At a subsequent group meeting, someone else was the new person, and that person looked to you to see how to behave. Over time, the composition of the group might turn over completely yet the behavior patterns continue unchanged. In this way, group norms and traditions endure (sometimespersisting across generations) without anyone’s guiding hand; it just happens: hence, the self-organization of stable patterns, continuity in patterns of relating.

New patterns can also self-organize; in the course of iterative reciprocal interactions very small changes or disturbances can amplify and spread. This phenomenon is popularly known as the Butterfly Effect, referring to the potential for miniscule air currents from the beating of a butterfly’s wings to interact with adjacent air currents, thus amplifying and spreading, ultimately resulting in a tornado half-way around the world.(16)

For an example closer to conversations and organizations, think of a moment when someone inadvertently said something to you that jogged your thinking and stimulated the germ of a new idea. Perhaps it was a particular turn of phrase he used or

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the serendipitous juxtaposition of his comment with a book you happened to be reading or a movie you just saw. Whatever the circumstances, that small accidental disturbance in your pattern of thinking sparked a new thought which you then expressed to your partner. He, in turn, grew excited by your idea and took it a step further. As the idea ping-ponged between you, it rapidly grew into a transformative new theory or project, or a whole new way of doing something. This new pattern of meaning emerged spontaneously. It was not on your agenda to create it; no one was in charge or in control of the process. It just happened.

Not all small disturbances propagate in this way; in fact, very few do. If we consider another self-organizing complex system, a sand pile onto which we are dropping individual grains of sand, we observe that most grains just stick where they land causing little or no disturbance. But occasionally just that one grain causes an avalanche. Far from being freak events, avalanches are intrinsic to the system, but it’s not possible to predict which grains will cause one.(17) No matter how fine the measurements we can make of a grain’s shape and momentum, the sand pile’s structure or the air currents through which the grain will fall, even finer differences can amplify and cascade, altering the outcome for the entire system.

Implications for PracticeThe organization-as-conversation perspective and its underlying principles of self

organization (complexity dynamics) offer us a more accurate understanding of organizations than that provided by the machine metaphor, and leads us to approach the work of organizational change in very different ways.

Emergent designThe most important implication is that while our work can and should be guided

by an overall direction or vision (itself a self-organizing theme that emerges and evolvesin conversation), we need to hold specific plans lightly, letting go of expectations of control. The Butterfly Effect and Sand Pile Model show us just how unpredictable is the work of organizational change and why an organization can never be like a machine. We can’t know in advance the consequences of what we do. Patterns may propagate themselves despite our most diligent efforts to change them, and transformative ideas and interactional patterns may emerge spontaneously from a single word or action. So creating and holding fast to a detailed blueprint that specifies every step in advance is futile, and worse, it creates its own obstacles in the form of tunnel vision, anxiety, blame and defensiveness, as we’ve seen previously.

An alternative approach is “emergent design,” (18,19) a dignified way of saying “making it up as we go along.” Emergent design involves a mindset of curiosity, flexibility and experimentation; “not knowing” is a virtue, not a deficiency. We take one step at a time, planning the next step only when we’ve seen the results of the previous one. This gives us the opportunity to identify and make use of emergent new patterns that we never could have anticipated. We introduce numerous small changes (disturbances) in the hope that some of them might ripple, stimulating further change, mindful that any one disturbance is unlikely to have much effect. Others have advocated similar approaches for rapid cycle change in waste and error reduction, and for achieving sustainable success in large corporations.(20-22)

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Paradoxical as it may seem, there is an important role for planning in emergent design. Even though a plan may evolve considerably over time, we need its content at any one point to help us coordinate our individual actions in that moment. Also, planning occasions conversations that are the medium for the emergence and evolution of shared ideas and relationships, the continuous renewal of shared understanding, common purpose, alignment and trust.

Focusing Attention on the Here and NowAnother important implication of the organization-as-conversation perspective is

to approach large scale organizational change at the level of everyday behaviors. It shifts our attention from what we should be doing (the grand blueprint) to what we are doing (the pattern-making that is taking place here and now).(6, p412) Our principal work as change agents is to engage everyone (not just the leaders) in reflecting on what ideas and cultural patterns we are enacting together, and to foster mindful participation, each personasking, “What am I doing in this very moment that contributes to those patterns? How can I act differently to interrupt existing patterns and start new ones?” An important form of leadership is to be first to disturb an existing pattern, putting our opioids and attachment at risk, in the hope of instigating a change. Gandhi expressed this perfectlywhen he said, “You must be the change you want to see in the world” [emphasis added].

Attending closely to the here and now of the organizational conversation also allows us to recognize and strengthen unheralded desirable patterns that are already present or are emerging. What opportunities might they offer? What might sustain or inhibit them? Methods such as Appreciative Inquiry and Positive Deviance use storytelling, positive feedback and cohesive group dynamics (attachment behavior) to reinforce such virtuous patterns.(23-26)

We can also notice the constraints that are shaping patterns in the organizational conversation. Self-organization requires the simultaneous presence of order and disorder, freedom and constraint. Constraints place conditions or limits on what each entity does within an ongoing interaction and bounds the range of possible patterns that might emerge. Some constraints are absolute and immutable (gravity, for example – we can’t have meetings on the ceiling). Others are more susceptible to change (for example, role expectations or systems of financial incentives). There is still freedom in the presence of a constraint – there are many ways it can be satisfied. We saw above how powerfully the risk of opioid withdrawal constrains the behavior of individuals in a group, yet there areany number of possible behaviors by which that constraint can be satisfied. We can better understand the ongoing process of pattern-making by noticing what physical, biological, psychological, social, financial, regulatory and other constraints are present in a given situation and which ones seem to be having the greatest effect. We can then consider how these constraints might be satisfied in other ways, or if the constraints themselves can be modified.

This detailed attention to process – to communication and relationship dynamics – differs sharply from the machine metaphor’s focus on outcomes, both actual and desired, and on blueprints for closing the gap between them. The organization-as-conversation perspective shows us that to change broad organization-wide patterns there is nowhere to work other than at the level of here-and-now interactions.

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Diversity and ResponsivenessA third implication for the work of organizational change is to recognize the

importance of diversity and responsiveness in the emergence of new conversational patterns.(6, p386-395) An organization’s diversity – the multiplicity of perspectives arising from differences in roles, personal histories and professional backgrounds – seeds novelty; it is the main source of serendipitous differences and disturbances that instigatenew patterns. When new patterns are desirable, we can think about how to enhance the expression of diversity, seeking participants with more varied perspectives and/or using appropriate facilitation methods to help people feel sufficiently safe and supported to disclose their differences.

Differences are necessary but not sufficient. There must also be responsiveness; people in conversation must be susceptible to being changed by one another. If I am holding rigidly to a pre-existing belief, or worse, not even listening to you, it doesn’t matter how rich is the difference you are trying to introduce; a new pattern will not be able to take hold and grow. So it’s important to notice the quality of listening and to help the participants work with their differences constructively. A variety of facilitation skills and meeting practices can support this goal.(27,28)

We should note that there are situations where new patterns are undesirable and where a high degree of control and consistency is essential. These tend to be situations with technical solutions – in which what needs to be done is already known – and that are complicated rather than complex.(10,29) If someday I need cardiac bypass surgery or a joint replacement, I do not want novel patterns emerging in the operating room; I want things to be done exactly according to protocol. In such situations, we want to reduce the expression of difference and diminish our capacity to change each other. Checklists and protocols focus conversation along relatively narrow channels and constrain the behavioral patterns that can emerge. We can manage diversity and responsiveness according to whether we need novelty or stability, bearing in mind that most organizational change scenarios do not have technical solutions; the way forward is not known.

On my flight to Indianapolis for the first meeting of the culture change project at IUSM, my worries about not knowing how to conduct this project intensified. A whole scenario played out before me: feeling the need to have a master plan, the project team would create a grand 3-year design involving lots of training sessions and quarterly milestones that we would fail to meet, making us increasingly anxious that we would blow this historic opportunity, causing us to try even harder to control things which would only push us farther off course. No, we had to avoid that whole direction; we would go down in flames.

Then it dawned on me that not knowing how to plan this big project wasn’t a problem, it was the answer. Embracing not-knowing would release us from the tunnel vision of our own solutions and open us to more possibilities. It would remind us to engage more people in shaping the project and to trust IUSM as the best source of its own answers. Rather than telling people how to implement the new culture we could invite them to reflect on the patterns of relating they enact in each moment, how they are participating and what opportunities they have to participate differently.

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Not-knowing would also free us from the unrealistic expectation that we could design and control this whole project. The only thing for us to design was the first step, and only when that was done – when we could see what happened, who was drawn to the project, and what ideas they had – could we discern the next step. We had to let this project emerge.

As our first step, we chose to conduct an Appreciative Inquiry, assembling a team of faculty, residents and students who gathered stories from 80 people about moments when IUSM’s culture was at its best. We analyzed the stories and presented the results back to the IUSM community, setting in motion waves of next steps that we never could have planned. The practice of appreciative storytelling spread widely, helping people become more mindful of relational process. They started to see their organization in a more positive light (the organizational identity began to change). Many people were attracted to the project, bringing with them all kinds of ideas that never would have occurred to us: the Admissions Committee redesigned its interviewing and selection process; the deans changed the process for allocating discretionary funds; the Academic Standards Committee changed the way it responded to unfavorable course evaluations.Thanks to these and many other changes that rippled out from that initial disturbance, the organizational culture at IUSM really did begin to change.(18)

Implications for ResearchIssues of access, quality and unsustainable costs are driving a growing demand for

studies at the organizational/implementation (T3) end of the research spectrum.(30) The leading edge of health services research has already moved well beyond the organization-as-machine perspective. For example, Aiken and her colleagues have been studying the effect on clinical outcomes of workplace environments that encourage more participatory (as contrasted with top down) decision-making.(31) Marvel, Safran and their colleagues are exploring the relational patterns of everyday administrative conversation.(32,33)Gittell and her associates have developed a measure of teams’ capacity for constructive self-organization.(34) Glouberman and Zimmerman, Greenhalgh and Russell, Dopson and Fitzgerald and Gabbay and le May show clearly that the translation of evidence into practice and policy is not simply a matter of synthesizing research findings and drawing up care maps (blueprints) but rather an emergent social process subject to the unpredictable influence of local political and contextual factors.(29,35-37)

Notwithstanding these and other innovations, the main body of organizational/implementation research might further embrace implications of the organization-as-conversation perspective. First, the process and content of research must not inadvertently reinforce the machine model. Recognizing that we can act within but not upon organizations, we can abandon the fiction of the detached scientific observer and instead implement consistently the principles of participatory and action research.(38,39) We can also abandon the expectation that research will provide generalizable context-independent solutions for changing organizations. Its purpose is not to provide the answer but to provide insights and innovations of help to local actors who must find their own local answers.

Accordingly, in the design and peer-review of organizational change research, we should not be looking as much to methods that attempt to eliminate local contextual factors (notably the randomized controlled trial) as to processual and qualitative methods

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that explicate these factors in detail.(40) We need rich accounts of how the patterns that constitute organizational knowledge and culture form and spread, and explorations of the nature, impact and mutability of the many various constraints in that process. Understanding organizational change projects as stories-in-progress (themes and relationships under continuous construction) and research reports as stories about these stories, we can recognize the essential role of case studies and the need for narrative analysis, rigorously applied.(41,42)

A new grant-review process will be needed to support projects based on emergent design, for which a method cannot be pre-specified. Such a process might focus instead on establishing the need for the project and opportunities it presents, the receptivity of the setting, and the capacity of the project team to undertake emergent work.

Closing reflectionsWe’ve reviewed the assumptions of the machine metaphor and seen its limitations

as a guide for action in a world of self-organizing ideas and relational patterns. We’ve considered what it means to see an organization as a conversation: understanding that we are always acting within and not upon the organization; recognizing that organizational identity, knowledge and culture are being created continuously here-and-now in the process of human interaction; cultivating a discipline of reflecting on the patterns we are creating in each moment so we can participate more mindfully; fostering diversity and responsiveness to favor the emergence of new patterns; and taking an emergent approach to organizational change that values planning but holds plans lightly.

Changing how we think about organizational change is itself a change project. This article is one of various attempts on my part to introduce disturbances in the current self-propagating patterns of thinking about organizations. My hope is that these ideas will spread into your thinking and conversation, and as you develop them further, they will come back to change me.

Acknowledgements

This article represents my own interpretation of ideas developed by Ralph Stacey, Patricia Shaw, Doug Griffin, and many other colleagues at the Complexity and Management Centre of the University of Hertfordshire. I also gratefully acknowledge Penny Williamson, Diane Robbins and our colleagues in Leading Organizations to Health; Alison Donaldson, Howard Beckman, Dan Duffy, Tom Smith, and my many clients – most notably Tom Inui, Deb Litzelman, Rich Frankel, Bud Baldwin, Ann Cottingham, Dave Mossbarger, Craig Brater and so many others at the Indiana University School of Medicine – for helping me to better understand and live into these ideas. This work was presented in part at the Regenstrief Institute Conference, Turkey Run, Indiana, October 2, 2007.

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� 2007 Anthony L. Suchman and Penelope R. Williamson

DRAFT: Please do not copy, circulate, distribute or cite without checking with us first. Thanks!

To appear in: Suchman A, Sluyter D, and Williamson, P. Leading Organizations to Health: Transforming Healthcare Organizations with Methods from Complexity, Positive

Psychology and Relationship-Centered Care

APPENDIX 1: PRINCIPLES AND PRACTICES OF RELATIONSHIP-CENTERED MEETINGS

Anthony L. Suchman, MD and Penelope R. Williamson, ScDRelationship Centered Health Care

The quality of relationships within a work team or committee has a profound effect onthe group’s results. It determines their willingness to bring forward their diversity and differences as a resource for creativity, their openness to change, their motivation and initiative, and their commitment to the group and its work. Many (if not most) meetings are conducted in a way that actually inhibit relationships and engaged conversation, resulting in meetings that feel dull and unproductive. Fortunately, there are some straightforward principles and simple meeting formats that can make meetings more relational and elicit high-quality participation. These methods require no additional time, only a little bit of courage to try something new. You can provide the leadership needed to suggest or implement these methods regardless of whether you are a team leader or a team member.

Principle #1: Invest time in relationship building; it will pay large dividends in efficiency and performance. When members of a team know and trust each other, people can say what they think and explore each others’ positions. Differences of opinion and perspective are a stimulus for creativity, not conflict. Meetings are enjoyable and the group makes rapid progress. Conversely, when people don’t know each other well, they get hung up on stereotypes (“what do you expect from an immunologist, or a social worker?”). They hold their ideas back for fear of ridicule and they waste a lot of time defending themselves and protecting their turf, time that could be better devoted to the work at hand. Often the urgency of the work makes it tempting to short-cut relationship building (“we don’t have time for this ‘soft stuff,’ there’s real work to do”) but it is always a false economy. The more urgent the work, the greater the likelihood of inadvertent relational breaches that amplify over time, the more urgently good relationships are needed, and the poorer the efficiency and outcomes will be if they are lacking.

Methods

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Initial meeting: There are many ways to help people get to know each other at the first meeting of a group. Participants can take turns introducing themselves, saying a bit about what they had to do or give up to attend the meeting and why it was important to do so. And/or they can tell a brief story about how they have come to be where they are at this point in their careers and lives. If the group numbers between 8 and 16, you might invite people to divide into pairs. Peopletake turns interviewing each other for a few minutes using the questions above, then when the whole group reconvenes each person introduces her/his partner. If the group numbers 8 or less, you might still use the paired interview approach or you can invite people to tell their stories directly to the whole group. In the latter case, it helps establish trust in the group to give people the option of passing if they’d rather not address the whole group (people rarely avail themselves of that option but it makes them comfortable to know they have it).

Subsequent meetings: At the start of each meeting, it’s helpful to begin with a round of “checking-in,” offering an invitation to each person (always with the option to pass) of reflecting on how they’re doing at the moment or what might be going on for them outside of the meeting that might be diverting their attention. Often simply naming the distraction helps to ameliorate it, and if it is something truly difficult (a child’s or parent’s illness or a major home repair in progress, for instance), the team members can offer support and will know not to take it personally if that person is observed during the meeting to be staring off into space and scowling.

Another approach to check-in is to offer each person an opportunity to describe something that has gone well since the previous meeting.

Principle #2: Foster high quality conversation. The “free for all” conversationalformat at most meetings wastes time and potential. People have to fight to get the floor only to be interrupted before they can complete their thoughts; some people are not heard from at all. This leads to poor listening, ineffective articulation of ideas, a poor sense of teamwork and low commitment to any decisions that result. So instead of a free-for-all, use a little light structure in the service of better conversation.

Methods

Nominal group process: This is just a fancy term for giving each person in turn aspecified amount of time without interruption to say what they think. You can allow a brief period of questioning before proceeding to the next person, or you can wait to hear from everyone before proceeding to questions and/or freeform dialog. In one variation, people suggest one idea at a time and keep going around the circle until there are no further ideas. Recording ideas on a board or flip chart can ensure that ideas are not lost. It’s often useful to engage in another round of nominal group process after a discussion has been in progress for a while to see what level of consensus exists and what issues still need more attention.

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Talking stick: This method involves using an object (traditionally a stick, but any object will do) to signify who has the floor. After finishing, a speaker passes the object to someone else who then has the floor. This method brings a little order to the conversation and helps people finish their thoughts without interruption.

Principle #3: Explore difference with openness and curiosity. When faced with a difference of opinion, people are all too easily hooked into a struggle over who’s right and who’s wrong. They fight as if their lives are at stake, and it’s no wonder given all the humiliation associated with being wrong in traditional medical learning environments. The challenge here is to recognize that most situations are more complex than any one person can grasp, that everyone has a unique piece of the puzzle, and if anyone’s piece is lost everybody loses. When people see things differently, most of the time they both are right.

Methods

The cone in the box: The figure reproduced below is a simple and effective graphic for helping people recognize that different perspectives are not mutually exclusive.i It shows a cone inside a box. People looking through a peephole at point A will see a circle, and through point B a triangle. Their observations may seem mutually incompatible and they will argue forever unless they can get past the belief that someone else’s different perception invalidates their own and accept that reality is more complex than what they are seeing on their own.

A

B

Cone in the Box

Listen for Internal Reactions: A failsafe indicator that you have a difference of opinion is your internal reaction. The most useful thing you can do when you suddenly experience a strong feeling (eg., anger, defensiveness, humiliation) in response to what someone else says or does is to pause for a moment and “turn to

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wonder”-- “I wonder why I’m feeling this way?” “I wonder what led him or her to that stance?” The discipline of shifting from “knowing that you are right” to curiosity about your response allows you to move to Inquiry.

Inquiry and advocacy: When encountering a difference of opinion, presume that the other person is competent and conscientious. Resist the initial temptation to argue and instead use inquiry – exploratory questions – to better understand the other person’s views and reasoning. If you can show that you understand his/her view by accurately reflecting it back, so much the better. Only then is it time toadvocate your own perspective, clearly explaining your reasoning. And by then, you may have discovered there is in fact no difference, or that the heart of the difference is something other than what you thought at first, so you can respond more effectively. As a facilitator, you can help your group recognize when they are getting stuck in a right-wrong conversation and invite them to use more inquiry and less advocacy to find their way through.

Principle #4: In pursuing change, learn from successes. Most groups working on organizational change focus on problems, trying to identify and fix the root causes. The major problem with this time-honored approach is that the problems are too often equated with people. No one likes to be a problem, so people divert a lot of energy into defending themselves to avoid shame; the conversation makes little headway. An effective and Zen-like alternative is to seek out and learn from instances in which the desired change is already present. They’re almost always around if you look for them.

Method

Appreciative Inquiry: This philosophy and methodology for organizational change is based on discovering and building upon the existing capacity within an organization. For example, if we want to foster better interdisciplinary collaboration, we’ll make more progress by learning from successful instances –what went right, what factors made it possible, and how do we do more of that –than discussing where things went wrong and why. Curiously, we’ll end up talking about exactly the same issues, attitudes and behaviors in either conversation, but with very different emotional tones that profoundly influence people’s openness to change. A typical AI process begins with people pairing up and taking turns telling each other stories of successful collaboration. The interviewer can explore the partner’s experience in more detail using questions such as:

what did you do or bring to the situation that contributed to the success, who else was involved and what did they do that helped? what aspects of the setting or situation made a difference? what useful lessons can we take from this story?

Partners can then present each other’s stories and lessons learned back to the whole group. This method is, in fact, a powerful form of participative inquiry. It

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invites people to step forward from a place of capacity rather than defensiveness, and helps people feel more hopeful and welcoming of change.

Appreciative debriefing: A similar approach can be applied in miniature at the close of each meeting. You can invite (with the option of passing, as always) each participant to reflect on moments during the meeting that they found particularly useful, important or engaging. This encourages people to become more aware of the process of their meetings and to discover how they can be helpful to each other. Positively reinforcing these helpful behaviors increases the likelihood of their use in future meetings and builds the sense of connection in the group, thus serving Principle #1.

Principle #5: Trust the process; don’t try to control the outcome. Good group process draws forth the best capacity of the group. You will no doubt find yourself heading into some meetings convinced that you already know what decision the group should make, and trying (subtly, or so you think) to steer the group towards your predetermined outcome. There are two major problems with this approach: (1) people don’t like feeling manipulated; they will fight you and will be unmotivated to follow through. (2) The group is smarter than you are, so your solution is unlikely to be as good as what the group would come up with. Rather than focusing on the desired outcome, focus on maximizing the quality of the process – on the quality of relationships and trust, and on the quality of listening, exploring, advocating and understanding. If the process is as good as possible, the best possible outcome will result.

Methods

All of the above!

The relationship-centered principles outlined above rest on a strong body of evidence. Relationship quality is well-associated with a wide variety of organizational outcomes in healthcare including quality and safety of care, cost, patient and staff satisfaction, and the capacity to learn new procedures. The principles and methods are also easy to apply. They may be unfamiliar and may feel a bit awkward at first. But if you share your awkwardness with the group and let them know what you’re trying to do and why, they will support you. Just remember what you are trying to accomplish – creating a more relational environment in which to work and get care. Bold change is accomplished by people who are willing to risk something new. Using these simple principles and methods, you can help your teams reach a new level of performance and engagement. We create the new model by living it in each meeting, and it will grow in ways none of us can imagine. May you have courage and success!

i Brown J. A Leader’s Guide to Reflective Practice. Victoria, BC: Trafford Publishing, 2007.

RELATIONSHIP CENTERED ADMINISTRATION: PARTNERSHIP PROCESS FOR CLINICAL AND ORGANIZATIONAL WORK

AN ANNOTATED BIBLIOGRAPHY

Relationship Centered Care Tresolini CP and the Pew-Fetzer Task Force. Health professions education and relationship-centered Care. San Francisco, CA: Pew Health Professions Commission, 1994.

The original presentation of the term “Relationship-centered care,” which was intended to convey “the importance of interaction among people as the foundation of any therapeutic or healing activity.” Available from the Pew Health Professions Commission at the Center for the Health Professions, University fo California, San Francisco, 1388 Sutter St, Suite 805, San Francisco, CA 94109.

Beach MC, Inui T, and the Relationship-Centered Care Research Network. Relationship-centered care: A constructive reframing. J Gen Intern Med 2006; 21: S3-S8.

Reviews the history and context of the Pew-Fetzer Task Force’s report that first introduced the term “relationship-centered care” and proposes four fundamental principles. Note: this paper is included in a special supplement to J Gen Intern Med devoted entirely to RCC.

Wylie JL, Wagenfeld-Heintz E. Development of relationship-centered care. J Health Quality 2004; 26(1):14-21.

A literature review on relationship-centered care describing how the concept has evolved since its introduction in 1994. The most salient developments these authors identify are a more engaged and capable role for patients and increased attention to interdisciplinary collaboration.

Suchman AL, Botelho RJ, Hinton-Walker P (eds). Partnerships in Healthcare: Transforming Relational Process. Rochester, NY: University of Rochester Press, 1998

Includes an introductory section on theoretical perspectives partnership, followed by sections on partnership in patient-clinician relationships, healthcare teams, partnership between community organizations and educational partnerships

Suchman AL. Control and relation: Two foundational values and their consequences. In Suchman AL, Hinton Walker P, Botelho RJ (eds). Partnerships in Healthcare: Transforming Relational Process Rochester, NY: University of Rochester Press, 1998.

Compares two value sets, one based on control and the other on relations, with regard to clinicians’ goals, the patterns of social relationships, approaches to gathering and using knowledge, and clinicians’ sources of existential security.

Rice AH. Interdisciplinary collaboration in health care: Education, practice and research. National Academies of Practice Forum 2000;2:59-73.

Recent literature review on interdisciplinary collaboration. Doherty WJ, Mendenhall TJ. Citizen healthcare. A model for engaging patients, families and communities as coproducers of health. Families, Systems and Health 2006; 24:251-63.

Describes innovative and exemplary work at the level of health-system community partnership, offering principles and three case studies.

© 2009 Anthony L. Suchman

Saizow R, Clark W, Novack D (eds). Doc.com: An interactive learning resource for healthcare communication. St. Louis, MO: American Academy on Communication in Healthcare, 2006. (available at www.aachonline.org)

A multimedia self-directed learning resource to help develop the communication and partnership skills needed for working with patients, family members and colleagues on the healthcare team.

Silverman J, Kurtz S, Draper J. Skills for communicating with patients. 2nd ed. Abingden, Oxon, UK: Radcliffe Medical Press; 2004. Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine. Abingdon, Oxon, UK: Radcliffe Medical Press; 1998.

The first book of this pair is an entirely evidence-based textbook on communication and relationship skills. It represents one of the most comprehensive reviews of the research literature in this domain. The second book is on educational methods related to communication and relationship skills.

Relationship Centered Administration Hepworth J, Cushman R. Creating collaborative environments for clinical care and training: From cacophony to symphony and jazz. Clinics in Family Practice 2001; 3(1):63-75.

Beginning with a case study of outstanding clinical collaboration in a family medicine practice, the article explores key dimensions of collaboration and how the work environment can facilitate it.

Marvel K, Bailey A, Pfaffly C, Gunn W, Beckman H. Relationship-centered administration: Transferring communication skills from the exam room to the conference room. J Healthcare Management 2003; 48(2):112-123.

The researchers studied a convenience sample of 45 administrative meetings in healthcare organizations to assess the frequency and types of relationship-centered behaviors. They found a number of parallels between the communication dynamics of administrative meetings and medical encounters.

Risdon C, Rowe M, Neuwirth Z, Suchman A. Communicating with colleagues. In Novack D, Saizow R, Clark B. Doc.Com (version 2.1): An interactive learning resource for health care communication. Available at www.aachonline.org.

Describes core principles and practices for establishing effective teamwork and relational work environments.

Safran DG, Miller W, Beckman HB. Organizational dimensions of relationship-centered care. J Gen Intern Med 2006; 21: S9-S15.

An excellent review of literature linking organizational culture to a variety of outcomes, including clinical outcomes, length-of-stay and employee morale. It also presents a five-component model of relationship-centered organizations.

Suchman AL. The foundational metaphors and theories of relationship-centered administration. Rochester, NY: Relationship Centered Health Care, 2006. http://rchcweb.com/Portals/0/foundational_metaphors_and_theories_of_rcadmin.pdf

Contrasts the implications of viewing organizations as machines versus conversations and proposes a new approach to organizational change that integrates insights from Complex Responsive Processes of Relating, Appreciative Inquiry, Self Determination Theory, Personal Formation and other perspectives.


http://www.aachonline.org/

http://www.aachonline.org/

Suchman AL. The influence of healthcare organizations on well-being. Western J Med 2001:174:43-47.

Healthcare organizations influence the well-being of individuals who work with or within them by patterning their perceptions, thoughts, feelings, expectations and behaviors. Organizational tendencies toward depersonalization, control and pathology-oriented perception adversely effect well-being, but can be modified by careful attention to language and behavior on the part of everyone in the organization, particularly leaders.

Suchman AL, Deci E, McDaniel SH, Beckman HB. Relationship-Centered Administration: A Case Study in a Community Hospital Department of Medicine. In Quill TE, Frankel RM, McDaniel SH (eds). The Biopsychosocial Approach: Past, Present and Future. University of Rochester Press, 2003:180-195.

This paper describes the key principles of relationship-centered care and their application in the administration of health care organizations.

Suchman AL, Williamson PR. Principles and practices of relationship-centered meetings. Rochester, NY: Relationship Centered Health Care, 2006. http://rchcweb.com/Portals/0/Principles_and_practices_of_relationship-centered_meetings.pdf

Describes several methods that can be used at meetings to foster responsiveness and diversity and to promote a relationship-centered work environment.

Williamson PR, Suchman AL, Cronin JCJ, Robbins DB. Relationship-Centered Consulting. Reflections, The Society for Organizational Learning Journal. 2001;3:20-27.

Describes a relationship-centered approach to consulting and management in healthcare organizations. The values and methodology of this approach mirror those of relationship-centered care, thus creating an opportunity for the organization's leaders and staff to learn about relationship-centered process directly through their own experience.

The effect of relationships on…

…Clinical outcomes

Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27S:110-127.

A review of this team’s classic studies showing the positive effect of active patient participation on measurable clinical outcomes including reductions in blood pressure, cholesterol and glycohemoglobin.

Williams GC, Deci EL, Ryan RM. Building healthcare partnerships by supporting autonomy: Promoting maintained behavior change and positive health outcomes. In Suchman AL, Botelho RJ, Hinton-Walker P. Partnerships in Healthcare: Transforming Relational Process. Rochester NY: University of Rochester Press, 1998:67-88.

A detailed review of primary research demonstrating that patients are more likely to undertake and maintain health-promoting behaviors in a treatment climate that they perceive to be autonomy supportive (as compared to controlling) and caring.

Gittell JH, Fairfield KM, Bierbaum B, et al. Impact of relational coordination on quality of care, postoperative pain and functioning and length of stay. Medical Care 2000; 38:807-19.


A high degree of “relational coordination” (frequent, timely communication; problem solving; shared goals; shared knowledge and mutual respect among healthcare providers) was associated with improved patient experience of care and reduced length of stay in hip and knee replacement surgery.

Shortell SM, Jones RH, Rademaker AW, et al. Assessing the impact of total quality management and organizational culture on multiple outcomes of care for coronary artery bypass graft surgery patients. Med Care 2000; 38: 207-17.

Patients’ functional status 6 months after surgery was positively associated with a collaborative team culture. Care was more efficient, as well.

Cuff PA, Vanselow N. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Washington, DC: National Academies of Science, 2003.

This monograph reviews the rationale for and current practices regarding the teaching of behavioral and social sciences in medical schools. It includes a literature review on the effect of communication and relationship skills on clinical outcomes.

Berry LL, Parish,JT,Janakiraman R, Ogburn-Russell L,Couchman GR, Rayburn WL, Grisel J. Patients' commitment to their primary physician and why it matters. Ann Fam Med 2008;6:6-13.

Patients’ commitment to the relationship with their physician was positively associated with adherence and healthy eating behaviors. Also describes the development of a scale measure relationship commitment.

Sochalski J, Jaarsma T, Krumholz HM, Laramee A, McMurray JJ, Naylor MD, Rich MW, Riegel B, Stewart S. What Works In Chronic Care Management: The Case Of Heart Failure. Health Affairs 2009; 28(1): 179-189.

Programs using in-person communication achieved a significant reduction in readmissions and readmission days when compared with routine care patients and programs using telephonic communication. Also, programs using single heart failure experts were less effective in reducing hospital readmissions compared with multidisciplinary teams.

…Quality and safety Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med 1986;104:410-8.

This landmark study of 5000 patients cared for in 13 intensive care units found that the quality of the working relationship between physicians and nurses was the most important determinant of patient mortality rates.

Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care 1994; 32:771-87.

Risk adjusted mortality was lower at hospitals with collaborative work environments as compared with matched controls.

Committee on Quality of Health Care in America IOM. Crossing the quality chasm: A new health system of the 21st century. Washington, DC: National Academy Press; 2001


This landmark report from the Institute of Medicine identifies poor systems of coordination, communication and decision support as the major source of errors in healthcare.

Institute for Safe Medication Practice. Intimidation: Practitioners speak up about this unresolved problem (Part I). ISMP Medication Safety Alert 3/11/2004. http://www.ismp.org/newsletters/acutecare/articles/20040311_2.asp

This survey of 2095 hospital-based healthcare professionals showed that intimidation is a common experience and impedes communication to a point that jeopardizes patient safety. This was not just a matter of “a few bad apples,” not limited to physicians and not primarily a gender issue.

Uhlig PN, Brown J, Nason AJ, Camelio J, Kendall E, John M. Eisenberg Safety Awards. System innovation: Concord Hospital. Joint Comm J Qual Improvement 2002; 28:666-72.

An interdisciplinary care team model that included a structure communication protocol reduced mortality on a cardiovascular surgery unit by 56%. Staff satisfaction was also higher.

…Patient satisfaction and retention

Hoffer Gittell J, Weinberg D, Pfefferle S, Bishop C. Impact of relational coordination on job satisfaction and quality outcomes: a study of nursing homes. Human Resource Management Journal 2008;18:154-170

Higher quality of interprofessional communication and relationships in nursing homes were associated with higher levels of resident satisfaction with the quality of their living environment and higher job satisfaction for the staff.

Safran DG, Montgomery JE, Chang H, Murphy J, Rogers WH. Switching doctors: Predictors of voluntary disenrollment from a primary physician's practice. J Fam Pract. 2001;50:130-136.

Measures of relationship quality predicted voluntary disenrollment from primary care practices.

Schramm W. Unpublished marketing data from the Henry Ford Health System.

Demonstrates a strong relationship between patients’ ratings of physician relationship behavior and their decisions to re-enroll in the HMO.

…Cost

Anderson RA, McDaniel RR. RN participation in organizational decision making and improvements in resident outcomes. Health Care Manage Rev. 1999;24(1):7-16.

The active participation of nurses in administrative decision-making contributed to a reduction in costs an improvement in clinical outcomes.

Ashmos DP, Huonker JW, McDaniel RR. The effect of clinical professional and middle manager participation on hospital performance. Health Care Manage Rev 1998(3); 23:7-20.

This survey-based study shows that participation in hospital decision-making by clinicians and mid-level managers is associated with improved financial performance.


…Workforce health and satisfaction Revans RW. The hospital as a human system. Bull N Y Acad Med. 1996;73:418-29.

An obscure but classic study from 1962, just reprinted recently, showing correlations between rates of illness and absence in student nurses and the quality of the interpersonal environment of the hospitals through which they were rotating.

Spickard A, GabbeSG, Christensen J. Mid-career burnout in generalist and specialist physicians. JAMA 2002;288:1447-1450.

This excellent review article addresses many contributing and ameliorating factors, with the latter including workplace relationships, mentoring and support groups.

Suchman AL, Roter D, Green M, Lipkin M, Jr. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care. 1993;31:1083-92.

Relationship with patients was the strongest predictor of physician satisfaction with office visits. This relationship has been consistent across many studies of satisfaction with specific visits, career satisfaction and life satisfaction.

Tellis-Nayak V. A person-centered workplace: The foundation for person-centered caregiving in long-term care. J Am Med Dir Assoc 2007; 8: 46–54

Management approach and the work environment are powerful predictors of CNA satisfaction, loyalty, and commitment. The work environment also correlates with how families and state surveyors evaluate quality in a nursing facility.

Hoffer Gittell J. Relationships and resilience: Care provider responses to pressures from managed care. J Applied Behav Sci 2008;44:25-47.

The resilience of interprofessional orthopedic teams was positively associated with work practices that foster relationship and with the quality of communication and relationships among team members.

…Staff recruitment and retention

Ulrich BT, Buerhaus, PI, Donelan K, Norman Linda, Dittus R. How RNs view the work environment: Results of a national survey of registered nurses. JONA 2005;35:389-396.

Several findings in this survey of how 3500 randomly sampled nurses experienced their work environments address issues of relationship. Overall job satisfaction was associated with the quality of relationships with patients and with the opportunity to influence decisions about the workplace and patient care. The quality of relationship with supervisors and senior administrators was associated with work satisfaction and retention.

Rosenstein AH, Russel H, Lauve R. Disruptive physician behavior contributes to nursging shortage. The Physician Executive November-December 2002: 8-11. Rosenstein AH. Nurse-physician relationships: Impact on Nurse Satisfaction and retention. AJN 2002:102:26-34.

Two articles describing a large survey of nurses, physicians and executives that found a high prevalence of disruptive physician behavior and a strong link between that behavior and nurse satisfaction and retention. Various perspectives emerged from the study about responsibility, barriers and solutions.


Verdejo T. Case Study: The first defense in workforce stabilization is retention. HealthLeaders.com, June 25, 2001. http://www.healthleaders.com/news/feature1.php?contentid=25360

An article about an impressive, inexpensive and very successful program to enhance nurse retention by creating a mentoring program for new nurses. It shows how simple and effective culture change can be.

…Malpractice Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-70.

Depositions in most of the malpractice cases reviewed in this study revealed evidence of patients being seriously dissatisfied with the quality of their interactions with their physicians.

…Capacity for change and innovation

Wesorick B, Shiparski L, Troseth M, Wyngarden K. Partnership council field book. Grand Rapids, MI: Practice Field Publishing; 1997

State of the art approaches to changing the culture of healthcare organizations. Trust and partnership must be established before process redesign efforts can begin.

Edmondson A, Bohmer R, Pisano G. Speeding up team learning. Harvard Bus Rev 2001 (Oct.): 125-132.

This study of interdisciplinary cardiac surgery teams learning new microinvasive techniques found that teams in which everyone’s voice was valued and respected were able to adopt the new technology faster and with fewer errors than less collaborative teams.

Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist 2000;55:68-78

Self-determination theory describes three main factors that predicts internally motivated behavior change: a personal sense of competence, respect for the individual’s autonomy, and a context of supportive relationships. This theory has been validated by research in workplace, educational and medical settings.

Interpersonal and emotional neurobiology Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context, and regulation: Perspectives from affective neuroscience. Psychological Bulletin 2000; 126:890-909.

Reviews the neural basis of emotion with particularly emphasis on activities of the amygdala and prefrontal cortex. Also describes the effect of experience on neural circuitry and affective style. Discusses potential favorable health implications of enhanced emotional modulation.

Toward an interpersonal neurobiology of the developing mind: Attachment relationship, “mindsight,” and neural integration. Siegel D.J. Infant Mental Health Journal 2001; 22:67-94.


http://www.healthleaders.com/news/feature1.php?contentid=25360

Synthesizes diverse scientific evidence to describe the influence of social factors on brain development. Describes “the essential experiential ingredients that may facilitate the development of the mind, emotional well-being and psychological resilience…”

Hyperstructures and the biology of interpersonal dependence: Rethinking reciprocity and altruism. Smith T.S, Stevens G.T. Sociological Theory 2002;20(1):106-130.

Describes the dynamic tension between attachment and stimulation (as reflected in opioid and norepinephrine activity in the brain). Also presents striking results from agent-based computer modeling that demonstrates how this dynamic tension within individuals can account for the self-organization of common social patterns.

The roots of empathy: The shared manifold hypothesis and the neural basis of intersubjectivity. Gallese V. Psychopathology 2003;36:171–180.

Presents experimental data supporting the concept of “mirror neurons” which discharge similarly when an action is undertaken and when it is observed. Mirror neurons are proposed to be a biological basis for intersubjectivity.

Organizational Change and Complexity Broekstra G. An organization is a conversation. In D.Grant, T. Keenoy, & C. Swick (Eds.), Discourse and Organization London: Sage, 1998.

A fascinating (but dense) description of an important way of understanding organizations. It has a particularly excellent description of the dynamics of attention and expectations.

Plexus Institute: http://www.plexusinstitute.com/

Many resources available from this organization which is interested in applications of complexity science to healthcare. Nearly all their work is based on older complexity models (eg: complex adaptive systems) which were developed in the natural sciences and then applied by way of analogy or metaphor to human interactions.

Stacey R. Strategic management and organisational dynamics: The challenge of complexity. (3rd ed.) Harlow, England: Pearson Education, Ltd, 2000.

Stacey begins with an extensive review and critique of traditional management theory (which is based on linearity and control) and then introduces the theory of Complex Responsive Process, the first complexity theory developed specifically for describing human interactions. Destined to be a classic.

Stacey R. Complex responsive process in organizations: Learning and knowledge creation. London: Routledge, 2001.

Presents further elaboration of the theory of Complex Responsive Process with a particular focus on “knowing.”

Streatfield. PJ. The Paradox of Control in Organizations. London: Routledge, 2001.

Another excellent introduction to Complex Responsive Process, told from the practical perspective of an organizational manager and leaders who is “in charge but not in control,” the paradox referred to in the title.

Suchman AL. A new theoretical foundation for relationship-centered care. J Gen Intern Med 2006; 21:S40-S44.


An article summarizing the theory of Complex Responsive Process, exploring its relevance to relationship-centered care and its new perspectives on mind, self, communication and organizations. It highlights the theory’s emphasis on moment-to-moment relational process, the value of difference and diversity, and the importance of authentic and responsive participation.

Suchman AL, Willliamson PR, Litzelman DK, Frankel RM, Mossbarger DL, Inui TS and the Relationship-centered Care Initiative Discovery Team. Toward an informal curriculum that teaches professionalism: Transforming the social environment of a medical school. J Gen Intern Med 2004;19:499-502.

Describes the application of the theory of complex responsive processes and appreciative inquiry in a large scale organizational change initiative.

Suchman AL. Organizations as machines, organizations as conversations: Two core metaphors and their consequences. Medical Care 2010: in press.

Offers a critique of the traditional and widely-held view of organizations as machines, with its problematic emphasis on control. Proposes an alternative perspective that is grounded in the real-world dynamics of self-organizing human interaction and emphasizes mindfulness of relational process.

Organizational Change and Positive Psychology http://appreciativeinquiry.cwru.edu

A good place to start learning about Appreciative Inquiry. Provides some basic articles and lists many readings and resources.

Bushe GR, Khamisa A. When is appreciative inquiry transformational? A meta-case analysis. http://www.gervasebushe.ca/aimeta.htm. January 2004.

“…two qualities of appreciative inquiry, a focus on changing how people think instead of what people do, and a focus on supporting self-organizing change processes that flow from new ideas rather than leading implementation of centrally or consensually agreed upon changes…” appear to be most associated with transformational change in organizations. [Quote taken from the authors’ abstract.]

Cooperrider D, Whitney D. A positive revolution in change: Appreciative Inquiry. Case Western Reserve University. File whatisai.pdf can be downloaded at http://appreciativeinquiry.cwru.edu/intro/whatisai.cfm

An article providing an overview of the history, philosophy and structure of appreciative inquiry.

March DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ 2004;329;1177-1179.

An approach to fostering change that identifies individuals with better outcomes than their peers (positive deviance) and enables communities to adopt the behaviors that give rise to the improved outcomes.


http://www.gervasebushe.ca/aimeta.htm

Ryan, RM and Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist 55 (2000): 68-78.

Presents a practical and empirically-verified model of intrinsically-motivated behavior change that highlights 3 determinants: competence, autonomy support and a relational environment.

Suchman AL, Williamson PR, Robbins DB, Cronin CJC. Strategic planning as partnership building: Engaging the voice of the community. http://connection.cwru.edu/ai/uploads/Strategic Planning and Community Partnership-Heathcare.doc

A detailed case study in the use of Appreciative Inquiry in strategic planning.

Suchman AL, Willliamson PR, Litzelman DK, Frankel RM, Mossbarger DL, Inui TS and the Relationship-centered Care Initiative Discovery Team. Toward an informal curriculum that teaches professionalism: Transforming the social environment of a medical school. J Gen Intern Med 2004;19:499-502.

Describes use of AI in changing the informal curriculum (the organizational culture) of a large medical school.

Watkins JM, Mohr BJ. Appreciative inquiry: Change at the speed of imagination. San Francisco: Jossey-Bass/Pfeiffer; 2001.

Another recent and readable introduction to this methodology. Includes many case studies.

Prepared by: Anthony L. Suchman, MD, MA Senior Consultant Healthcare Consultancy, McArdle Ramerman & Company

For the most current version of this document and other related materials, visit www.rchcweb.com and click on Articles and Monographs under the Resources tab.


http://connection.cwru.edu/ai/uploads/Strategic%20Planning%20and%20Community%20Partnership-Heathcare.doc

http://connection.cwru.edu/ai/uploads/Strategic%20Planning%20and%20Community%20Partnership-Heathcare.doc

http://www.rchcweb.com/

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