The Case for Relational Quality Improvement in Health

Effective collaboration within health professional teams is important to provide the patients with holistic care in order to best support them to achieve their goals.

Good relationships go beyond those within the organisation itself but within a complex system such as healthcare, relationships need also be nurtured in how health services interact with their external environment and vice versa.

This includes applying principles of ‘emphatic understanding’ to interactions with colleagues to create a psychologically safe space which can allow health teams to flourish and in turn to be able to deliver high quality of care to patients.

By Dr Maria Kordowicz *

Chartered Psychologist & Senior Lecturer in Business Psychology

University of Lincoln, Lincolnshire, UK 

The Case for Relational Quality Improvement in Health 


Quality improvement in health can be described as a systematic approach to enhancing patient care. It is concerned with bringing about beneficial change in quality performance in health services, systems, organisation and delivery. Due to its systematic, often process-driven nature, healthcare quality improvement can be an arena filled with benchmarking, toolkits, financial appraisals and the language of managerialism.  The resulting proliferation of ‘quality’ metrics and standardised processes can at times detract from recognising the importance of the role effectiveness human relationships play in not only implementing but also sustaining change in healthcare. I reflect here about the role of the relational in improving healthcare quality and draw on my own research and experience to illustrate key arguments. Given the challenging global pandemic context, we are called on now more than ever to offer relational support to one another and to creatively use online technologies to facilitate connection in lieu of physical presence.

It is therefore salient to revisit understandings of human relationships at work and the extent to which they can enable effective healthcare systems.  There is a wealth of research within the business and human resource management arena which centres around how one can improve working relationships in the context of the corporation.  Evidence from the healthcare field concerns itself with the well-being of healthcare staff with enquiry often centred around clinician burnout. My own interest as an executive coach and trainee psychotherapist in person-centred and experiential therapy lies in the role of relational in enabling what Carl Rogers defined as ‘self-actualisation’ – our innate capacity to fulfil our full potential. In other words, my work consists of studying and teaching others how relationships can help us to thrive at work in the healthcare sector and beyond.

We also know from the perspective of the English National Health Service (NHS) that there is a growing disquiet among healthcare staff as to how enabling their working environment is and extent to which it contributes towards undermining their mental health. The annual NHS staff survey has for several years now indicated issues with a dissatisfied demotivated workforce as well as capturing feedback around instances of bullying.  We learned from the Francis Report looking into the atrocities that took place in Mid-Staffordshire NHS Foundation Trust in England that an unfavourable and suppressive organisational culture can play a key role in the extent to which quality of care is enacted or destabilised.  Indeed, recommendations from the Mid-Staffordshire enquiry centred around improving organisational cultures to enable individuals can speak up freely when quality of care is subpar, upholding principles of dignified care.

I have had a wide-ranging career including over a decade’s worth of senior healthcare management experience and I am now a Chartered Psychologist and university academic, researching health and social care organisations. Previously, I worked as an interim healthcare manager, which meant that I was posted to a service or a project to temporarily fill a vacancy gap. Often, the roles I undertook were within challenging services and I was tasked with improving their quality in a short period of time. I quickly learned that struggling services contained struggling teams, with poor and strained working relationships. In order to improve the relational within healthcare teams, we must first seek to understand what good relationships look like.

What constitutes good relationships in healthcare teams?

Our work evaluating Clinical Effectiveness Southwark – a quality improvement scheme in primary care in a deprived borough of South East London providing guides and online templates for chronic disease management – found that it was the sense of ‘teamness’ amongst the improvement team and the collaborative inclusive relationships they formed with a range of stakeholders, which enabled the programme of work to embed and gain ‘buy in’ locally. In this vein, Gittel and colleagues (2013) underline the importance of effective collaboration in healthcare to provide the patient with holistic care in order to best support them to achieve their goals. They explore some of the communication and cultural barriers to good relationships and propose that these deeply embedded behaviours and interaction patterns which may be specific to professional groups need to be transformed in order to improve the quality of patient care. This can be achieved over time through creating and working towards shared goals, generating co-produced knowledge and mutual respect across professional boundaries. The authors also see the potential here for enhanced relational working to improve the access to and quality of care at a scale beyond individual teams.

Further, in an earlier paper, Gittel and others (2009) argued that relationships within healthcare teams can be meaningfully coordinated by creating relational pathways of interdependent work which in turn foster high-performance healthcare systems. Indeed, Cramm and Nieboer (2012) discovered that formal relational coordination of disease-management clinicians from different disciplines improved the delivery of chronic illness care. However, whilst relational coordination is a systematic method of integrating tasks around relational touch points, it does not necessarily account for what constitutes personally rewarding and meaningful relationships within healthcare teams. For instance, rewarding social relationships can be viewed as an important component of wellbeing (Kansky & Diner, 2017) and poor wellbeing at work can in turn lead to healthcare professional burnout (Hall et al., 2016). In terms of quality improvement, the detrimental impact of clinician burnout on patient safety is well-documented (see Hall et al., 2016 for a review).

We know that relational competencies, such as good communication, are essential core skills that are associated with enhanced health outcomes and improved satisfaction with care (e.g. Meyer et al., 2009). In order for staff to deliver quality care, they no doubt require the necessary ‘bandwidth’ to withstand the demands and challenges of their working lives. There is a body of evidence from the business and management literature which indicates that employee wellbeing is upheld in workplaces where staff feel valued and work as part of cohesive teams with a shared vision and values (see Mickan & Roger, 2000 for a review). For instance, my colleague and I are currently completing some research conducted within a large multinational corporation which demonstrates how a simple and authentic ‘thank you’ holds much power in nurturing our working relationships. Indeed, a quote from one of our study’s participants is rather apt here: ‘saying “thank you” is so powerful because it lifts up the individual and it makes him strive harder in his work and given tasks. Being appreciated makes an individual motivated and will create a working environment free of resentments and frustrations’. We must however be mindful not to individualise the relational nor view poor relationships at work as the sole responsibility of staff. It is the ‘health’ of the wider organisation which has much impact on ‘teamness’ and cohesion – the influence factors such as a realistic workload, a well-resourced working environment and the appropriate skill mix and so forth cannot be underestimated.

Therefore, it is worth noting that good relationships go beyond those within the organisation itself but within a complex system such as healthcare, relationships need also be nurtured in how health services interact with their external environment and vice versa.  In particular, in a public taxpayer-funded healthcare system, the influence of top-down government policy on how healthcare teams operate is wide-ranging.  It is naïve not to consider how continuous change mandates driven by a change in government officials can undermine employee stability and in turn their morale and their wellbeing.  Therefore, there is a strong rationale for change programmes that are negotiated and co-produced locally in order to gain adequate ‘buy in’ from the stakeholders who matter – namely staff and patients.

Applying person-centred values to our work

As part of my present training as a person-centred and experiential psychotherapist, I am beginning to immerse myself in how the relational is understood through the lens of the discipline’s founding father – Carl Rogers. It is within groups, through our relationships with others, that our identities are negotiated and formed. In large part, we make sense of our context, and as part of this we negotiate what constitutes quality improvement, through our collective realities. Rogers identified some prerequisites to an effective therapeutic alliance – one that supports the client in their journey to self-actualisation – and I highlight two of these prerequisites as pointers towards improving our relationships at work. These are ‘empathic understanding’ – taking the time to listen and to seek to understand our colleagues, and ‘unconditional positive regard’ – the acceptance of a person within a non-judgmental space, so our colleagues can share their thoughts and feelings freely and without fear. Arguably, this is how healthcare professionals relate to their patients day in, day out. It is crucial to apply these principles towards our interactions with colleagues to create a psychologically safe space which can allow our team to flourish and in turn be able to deliver high quality of care to patients. We have seen some wonderful examples of person-centred interaction taking place with the aid of digital media, through remote team coffee breaks, writing drop ins, special interest online communities and the like. It goes without saying that exploiting the ‘new normal’ as a means of managerial digital surveillance of the ‘performance’ and outputs of health staff who can work from home will only undermine trust and relational safety.

Crucially, one cannot underestimate the time it takes to achieve engagement with quality improvement initiatives, as well as to forge effective working bonds and collaborations. Often, the quality improvement initiatives, which appear to have most positive outcomes, are those that are shaped within pre-existing teams with established effective working processes. Through our own work exploring how newly Primary Care Network leaders in England navigated these novel organisational forms, we learned of the importance of pre-existing relationships in order to achieve a clear mandate for realising an organisational purpose. Similarly, in their study of primary care reform, Scott and Hofmeyer (2007) called for the need to recognise pre-existing networks within a change context, including understanding their roles and relational impact in order to ‘establish a foundation for the diffusion of innovative practice patterns that will foster collaborative relationships and improve primary healthcare systems’.

As a final point, relational quality improvement should not only be concerned with how relationships can improve quality, but also about recognising how the quality of relationships itself may too need to be improved. Through a Rogerian lens, our interconnectedness with others contributes to the greater whole. Healthcare organisations sit at the interface of the individual and the society and human existence is not possible without co-existence – something that the pandemic has made us even more acutely aware of, not least in highly individualist societies. Here evidence-based government public health interventions such as mask-wearing have been received by some as an infringement of individual liberty, rather than as a small sacrifice for the benefit of many. These unprecedented times however call for unity and I therefore urge you not to forget how important your relationships with your colleagues are and the significant role they play in not only upholding quality of patient care, but also your own sense of wellbeing when it likely needs to be nurtured more than ever before.



*Dr Maria Kordowicz is a Chartered Psychologist and Trainee Psychotherapist, an executive coach working with NHS staff, Director of and Senior Lecturer in Business Psychology at the University of Lincoln. Find out more about Maria here: Twitter: @mariakordowicz