Organizations in virtually every industry are facing pressures to do more with less. Whether these pressures come from customers, supply chain partners, policy makers or regulators, organizations feel compelled to provide better, higher-quality outcomes, more rapidly, and at lower cost. As always when facing performance pressures, there are critical choices to be made. Namely, will we pursue low-road strategies that rely primarily on the reduction of pay and the degradation of working conditions? Or will we instead pursue the high-road strategies that produce positive outcomes for a broader range of stakeholders? High-road approaches to high performance are fundamentally relational, requiring not just human capital but social capital to integrate across difference, thus creating new value rather than simply redistributing it.

Relational coordination is simply coordinating work through relationships of shared goals, shared knowledge, and mutual respect. Together, these relational dimensions reinforce communication that is sufficiently frequent, timely, accurate, and problem-solving rather than blaming when things go wrong. Relational coordination is extremely practical, supporting a wide range of positive performance outcomes—efficiency, financial performance, quality, safety, client engagement, worker engagement—as well as the ability for organizations to learn, innovate, and adapt. Relational coordination works especially well under the challenging conditions of uncertainty, interdependence, and time constraints.

Relational coproduction happens when workers and their clients produce desired outcomes together by engaging in high-quality communication supported by relationships of shared goals, shared knowledge, and mutual respect. Rather than workers telling clients what they need, relational coproduction involves reciprocal interrelating between workers and clients regarding what should be done and how best to do it. Obstacles to relational coproduction include lack of accountability, lack of knowledge, and excessive attachment to professional autonomy. Traditional professional-client relationships may not even consider the possibility that clients have knowledge enabling them to contribute in a fundamental way to the achievement of desired outcomes. This chapter proposes a new model of professionalism based on "power with" rather than "power over."

We know from decades of research that leadership is instrumental for achieving organizational change, whether through the exercise of power or through the exercise of influence. In this chapter we explore relational leadership as an alternative to hierarchy, based on "power with" rather than "power over." More specifically, relational leadership is a process of reciprocal interrelating between leaders and those they lead. Relational leaders create influence in two ways: by developing shared goals, shared knowledge, and mutual respect with others—and by developing shared goals, shared knowledge, and mutual respect among others. Relational leadership requires that leaders have the courage to move beyond the divide-and-conquer strategy to purposely build connections among others.

Managers and frontline workers often develop relationships at work that enable them to get their jobs done. But these personal ties are not sufficiently reliable to achieve the performance outcomes that are at stake for their organizations, especially organizations that must deliver promised outcomes to multiple stakeholders without missing a beat, whether or not a particular individual happens to be present. Structures are needed to enable reliable performance outcomes, yet existing structures tend to be bureaucratic, creating strong ties within one's area of expertise and weak ties at critical handoffs. This chapter introduces organizational structures that range from selecting and training for teamwork, to shared protocols and shared information systems, designed to reinforce and strengthen relationships across the boundaries where they tend to be weak.

A Relational Model of Organizational Change proposes that three types of interventions—relational, work process, and structural—are needed to transform role relationships in a positive and sustainable way. Relational interventions enable participants to transform the way they see themselves and their role within their organization. Relational interventions include building a safe space within which to experiment with new ways of interrelating. To achieve positive sustainable changes in relationships, work process interventions are needed to apply the new dynamics to the work itself, enabling participants to visualize the work they are engaged in and identify opportunities to redesign that work to achieve the desired state. Even this is not sufficient however. Structural interventions are also needed to redesign existing structures to support and sustain the new ways of working together.

Group Health Cooperative gives us a chance to explore, up close, efforts to enhance relational coordination for the purpose of achieving high quality performance outcomes more efficiently. In the face of financial and system-level leadership challenges, Group Health's primary care leadership team decided to build on previous successes with lean process improvement by measuring and strengthening relational coordination among frontline care workers. Even though frontline workers and frontline leaders embraced these efforts, the challenges they faced were many, and successes were mixed with failures.

Promoting health and wellness in the community means moving away from a narrow focus on treating illness to a broader focus on fostering wellness. It is both more holistic and smarter from the standpoint of shifting investment from downstream consequences to upstream causes. But investing upstream creates a need for relational coordination and coproduction across a greater number of sectors. Varde Municipality of Denmark provides an opportunity to explore efforts to build relational coordination across multiple sectors as well as relational coproduction with citizens themselves. With leadership support from the mayor and the municipal CEO, and a focus on leadership development at the frontline, this change effort was on a path to achieving sustainable positive outcomes.

The Dartmouth-Hitchcock health system in central New Hampshire has long enjoyed a sterling reputation for healthcare delivery and innovation. Despite its impressive resources and accomplishments, there were some challenges as well. The Department of Surgery was facing tremendous performance pressures due in part to the shift toward accountable care. To respond to these challenges, the chair of surgery proposed two distinct change initiatives—building relational leadership among his surgical chiefs, and building relational coordination among frontline staff. We follow their journey closely, learning from its successes and its limitations.

What does it look like to build relational coordination among workers and relational coproduction with your customers, while supported by relational leadership throughout your organization? While no one organization can perfectly exemplify this integrated approach, Billings Clinic was moving in this direction with strong leadership support from frontline workers, unit leaders, middle managers and the CEO. In addition to assessing and feeding back relational coordination metrics, this change initiative used positive deviance and games of positive recognition such as RC Bingo. We observe frontline efforts to redesign structures including payment models, team meetings, and information systems. After starting in an area of existing strength, this change initiative begins spreading to other parts of the system through positive contagion.

Relational interventions are informed by process consultation, organizational development, and positive psychology. The underlying philosophy is that participants can assume a proactive role in transforming their role relationships with each other, their clients and their leaders, and that ultimate responsibility for change rests in their hands. In this chapter, we learn about relational interventions and the tools associated with them, such as safe spaces, relational mapping, the relational coordination survey, and facilitated dialogue. Interventions informed by relational coordination improve participants' capacity to self-manage their interdependence: to understand their common goals, to understand how their individual work fits into the larger work process, and to carry out their work with a mindfulness of how their actions affect the work of others.

While relational interventions are focused on transforming relationships among those doing the work, work process interventions are focused on transforming the work itself. Process improvement and relational coordination are often seen as competing approaches. For decades, however, sociotechnical systems designers have seen the two as complementary approaches for organizational change. This chapter introduces tools from popular methodologies, such as lean, and microsystems for carrying out work process interventions in three phases: assessing the current state, envisioning the desired state, then experimenting to achieve the desired state. Once participants use relational interventions to begin changing the way they communicate and relate across key boundaries, they are better able to use these tools to change the work itself.

Structural interventions are new structures introduced to support and sustain shared goals, shared knowledge, and mutual respect between workers, with their clients, and with their leaders—such as new forms of team meetings, or protocols to clarify roles and the connections between them, or boundary spanners whose role is to coordinate work, or hiring and training for teamwork, or revised structures for accountability and rewards, or newly designed supervisory roles, or shared conflict resolution practices, or shared information systems. While these new structures can support new relational dynamics, they cannot create these dynamics. When participants' sense of self is defined by the old relational dynamics, these new structures will feel unwelcome. These new structures are implemented successfully only when participants themselves see the need for them and participate in their design and implementation, having understood the principles of relational coordination, relational coproduction, and relational leadership through their own direct experience.

With the Relational Model of Organizational Change we have identified three types of interventions that together support sustained positive relational change: relational interventions to give birth to new patterns of interaction, work process interventions to diagnose and improve the work itself, and structural intervention to reinforce and sustain the new ways of working together. We have learned that these three types of interventions are quite synergistic. Given that they come from different "thought worlds," however, it is easy for change agents to become siloed. Perhaps the most powerful learning from this book is the critical role that change agents play in creating organizational change through small actions that have cumulative and transformative effects. The key is to carry out these small actions with intention, with awareness of one's power, as well as deliberate planning with others to create collective impact for positive change.