During the past 10 years, family practices have confronted a host of challenges such as managed care hassles, shrinking reimbursement, a proliferation of clinical guidelines and increasing pressures to improve quality and reduce medical errors. Despite this challenging environment, some practices have endured and even thrived.

To understand why certain practices have succeeded while others have struggled, our research group analyzed primary care practices across the country in terms of their clinical and financial outcomes. These studies, funded by the National Institutes of Health, the Agency for Healthcare Research and Quality, and the AAFP Center for Research in Family Medicine and Primary Care, have examined quantitative and qualitative data from more than 160 practices in Nebraska, New Jersey, Ohio and Pennsylvania and have resulted in more than 100 peer-reviewed publications focusing on practice functioning and quality of care. We’ve learned that practices are complex adaptive systems that evolve over time and respond to a host of internal and external factors that influence their outcomes.^1,2 According to our research, one of the key contributors to a practice’s success is the presence of functional work relationships. This article is intended to help practices understand seven characteristics of positive work relationships and learn how to foster these characteristics among physicians and staff.

What makes work relationships work?

We have observed seven interdependent characteristics of work relationships in successful practices. (To assess your practice’s performance in these areas, use the work relationship assessment form.)

Trust. This is the foundation for any successful collaboration. People in trusting relationships seek input from one another (and actually use it), and they allow one another to do their jobs without unnecessary oversight. Examples of trust include physicians allowing staff to use standing orders for services such as flu shots and practice managers making decisions based on input from staff. Individuals who trust one another can also openly discuss successes and failures to learn from them.

Diversity. Diversity can be defined as differences in the way people view the world. Whether it stems from differences in age, race, gender, education or experience, some diversity of thought will occur in any work setting. Successful practices do not merely tolerate diversity of opinions but encourage it. Diversity broadens the number of potential solutions and enables people in the practice to learn from one another.

Mindfulness. In mindful relationships, people are open to new ideas. A mindful practice avoids operating on autopilot, encourages everyone to express their ideas without fear of ridicule, criticism or punishment, and looks for ways to continually learn and improve.

Interrelatedness. This occurs when people are sensitive to the task at hand and understand how their work affects one another. In addition, they are continually aware of how each person contributes to the goals of the practice and the larger community. Practices that demonstrate this characteristic are better able to deal with unexpected events.

Respect. Respectful interactions are considerate, honest and tactful. People who respect one another value each other’s opinions and willingly change their minds in response to what others say. Respect is especially important in challenging situations, as it can help individuals focus on problem solving.

Varied interaction. Relationships in practices can be described as social or task related. Social relationships are personal and often based on activities that exist outside of work; task-related relationships are focused on professional issues. Practices should not view social and task-related relationships as mutually exclusive. In successful practices, a mixture of social and task-related relationships is required, and practices should encourage both.

Effective communication. Communication between individuals can be described as rich or lean. Rich channels, such as face-to-face interaction or telephone conversations, are preferred for messages with potentially unclear meanings or emotional content. Lean channels, such as e-mails or memos, are preferred for more routine messages. In successful practices, individuals understand that both rich and lean communication channels are necessary, and they know when to use each strategy.

How to get there

Fostering these characteristics of positive work relationships in your practice is not the responsibility of a single person, such as your practice manager. While leadership can play an important role, each member of a practice should be expected to lead by example. Modeling desired behavior is one of the most effective ways to encourage the systemic development of these relationship characteristics.

For example, physicians should treat staff with respect and recognize how their actions affect the rest of the practice. They should make an effort to communicate messages effectively and encourage both social and task-related relationships by being social themselves.

Practices also should allow time to meet and discuss important issues. Practices that meet often provide the opportunity for group interaction and reflection, which results in learning, increased understanding and appropriate action.

Finally, practices should pay close attention to other factors that can influence the quality of their work relationships, such as the hierarchical nature of the staff or the physical layout and organization of the practice. Anything that could potentially hinder the creation of successful work relationships should be examined.

Trust, diversity, mindfulness, interrelatedness, respect, varied interaction and effective communication may seem like simple concepts, but they are critical. When these characteristics are modeled, developed and nurtured, the practice has a better chance of operating successfully.