Relational coordination in inter-organizational settings. How does lack of proximity affect coordination between hospital-based and community-based healthcare providers?

Abstract

Introduction : With more care provided outside hospitals, coordination across organizational boundaries is needed. Relational Coordination RC represents a type of informal coordination that has been found to improve quality and efficiency of patient care in intra-organizational networks, but only few studies have examined RC in inter-organizational settings. This paper focuses on how structural challenges affect RC in this setting. Theory/Methods : Studies suggest that the positive outcomes of RC found in intra-organizational settings translate into inter-organizational settings. However, insights from the literature on Inter Organizational Collaboration IOC stress that a lack of technological, geographical and institutional proximity between network participants challenges informal coordination across organizational boundaries. Our pilot study was based on a qualitative case study approach to get an in-depth understanding of these potential challenges. We focused on a collaboration between a hospital-based geriatric team and a community-based acute care team offering home-based care for frail elders aiming to prevent avoidable acute hospital admissions in a major city in Denmark. Data consisted of seven semi-structured interviews plus 16 hours of participant observations. Results : Findings indicated that core tasks were largely coordinated through strong informal relationships. Especially a shared goal of providing high quality home-based care led to effective communication. However, previous differences in guidelines had created barriers for establishing strong relations. Managers overcame this lack of institutional proximity by introducing shared guidelines. Non-core tasks were marginally coordinated through informal relations. Lack of especially technological and geographical proximity challenged defining shared goals and procedures for information sharing. Management did not implement formal coordinating mechanisms to overcome these structural challenges. Discussions : Empirically the study adds to the limited number of studies focusing on inter-organizational network settings and identifies structural challenges to RC in this setting. Theoretically, the study introduces a distinction in the impact of the structural challenges between core and non-core tasks. In core tasks, relationships mostly emerged independently of structural challenges, confirming findings from intra-organizational settings. For non-core tasks structural barriers hindered the forming of strong informal relationships, as the IOC literature suggests. This distinction was further deepened as management tended to implement formal coordination to overcome structural challenges only for core tasks that were important for overall goal achievement and performed at a higher frequency. Conclusions : Core tasks were coordinated through strong relationships in the inter-organizational network; this depended partly on formal coordination mechanisms to overcome structural barriers. These structures largely hinder RC of non-core tasks. Lessons learned : With their lack of proximity, inter-organizational structures challenge RC especially in non-core tasks and partly in core tasks. Formal coordination mechanisms can mitigate, pointing to the importance of an effective interplay with formal coordination mechanisms for RC in inter-organizational settings. Limitations : Findings are highly context specific and require detailed assessment of transferability to other contexts. Further, limited data of the pilot study does not allow drawing robust conclusions. Suggestions for future research : Future qualitative studies should aim to provide a rich description of both context and coordination in addition to gathering more data.