Building Social Capital as a Strategy to Improve Healthcare Performance

Alexandra Norrish
Nikola Biller-Andorno
Padhraig Ryan
Thomas H. Lee



From Harvard Medical School, Harvard School of Public Health, the United Kingdom

National Health Service, the University of Zurich, and Partners Healthcare System, Boston,

MA. Contact: thlee@partners.org


Healthcare executives focus a tremendous amount of time and energy on building the financial capital of their organizations. This is right and proper: financial health is a prerequisite to allow an organization to fulfil its mission of delivering healthcare. But there is another capital which is rarely the explicit focus of organizational leaders, but which may be just as essential as financial resources for health care delivery systems facing the challenges that lie ahead – social capital. This article does not attempt to summarise the extensive academic literature around social capital. It does, however, attempt to fill the gap between some of the academic studies and practice, by suggesting how some approaches to building social capital might be operationalized in healthcare.


What is social capital?

Social capital is a term widely used outside health care, but less so within it – perhaps because it is not easy to define: the literature is filled with competing definitions. For the purpose of this article, we use Robert Putnam’s definition of social capital as “social networks and norms of reciprocity”1 : in an organization, this translates into the ways in which people relate to each other and work together.

Social capital is underpinned by “shared norms, values and understandings that facilitate co-operation within or among groups”2. In a healthcare organization, social capital can refer to networks within teams, between different groups of staff, between staff and senior leadership, and between the organization and other healthcare organizations in the wider field. Social capital – of a different sort, based on close interaction rather than membership of a network - can also be built between staff and patients and their families.3

One distinction that is often drawn is between ‘bonding’ and ‘bridging’ social capital4-7. ‘Bonding’ social capital refers to the contacts and trust between individuals in a small, ‘closed’ groups such as the nurses on a ward, or the team of physicians working in a small group practice. Bonding capital reinforces social bonds and can strengthen the sharing of information within a team ,while often reinforcing group norms. It is, in effect, the trust and familiarity that allows members of a healthcare team to share information and work smoothly together.

‘Bridging’ social capital, on the other hand, arises from links formed between members of different groups: for example links to other specialty teams, to the hospital leadership, or to a community of researchers. It can benefit the whole team (for example if one member gains experience of a new process and is able to pass this on to colleagues); or it may primarily benefit the person who is acting as the bridge and has thus gained access to new knowledge or powerful allies. One useful shorthand describes bonding social capital as useful for ‘getting by’ while bridging social capital is for ‘getting ahead’8.



Why does social capital matter?

Because of scientific progress, many clinical personnel are involved in giving individual patients the benefit of “state of the art” medicine, and to do so efficiently, those personnel must do more than express the intention to work together. There are, in fact, multiple dimensions to the development of social capital in healthcare, and they should ideally be addressed with the same rigor and discipline as are applied to development of financial capital.

Social capital has powerful implications for healthcare organizations – and with good reason, since healthcare organizations around the world are struggling with the need to build more effective teams, to improve information flows between clinicians and with patients, and to be more open to innovation and new ideas from outside. More than a decade of studying social capital in healthcare has found that higher levels of social capital may be associated

with improved co-ordination of healthcare 9 10,increased job satisfaction for staff 11, greater organizational commitment of healthcare staff 9,12,13, and faster dissemination of evidence-based medicine14. There is evidence that increased social capital is associated with higher outcomes for patients, perhaps because better communication leads to reduced stays and increased functional health15.

From an ethical standpoint, strengthening interpersonal relationships can help a healthcare organization to fulfil its mission and live its values 16. And as a business strategy, building social capital can give a healthcare provider a strong edge over its competitors: one definition of social capital is simply “sustainable organizational advantage”17.

Social capital does have a less positive aspect – what Putnam termed the ‘dark side of social capital’6. For example, while strong relationships within a team - high levels of bonding capital - can improve patient experience by improving flows of information, they can also undermine patient care. The strong sense of a group norm can make it well-nigh impossible to introduce new evidence-based treatments. High bonding capital easily turns into factions (physicians versus nurses, or administrative staff against the demands of clinicians). . Social capital is a resource available to all the members of a group or a network, and it may be used for purposes that the leadership of a healthcare organization would prefer not to see.

Despite this, the potential for good is significant. But if social capital can have positive effects in health care, and if it has been so extensively studied, why is more formal attention not paid to it in practice18? Why does every hospital board not have a strategy to build its own organization’s social capital?

One reason is that ‘social capital’ is such a vague concept. It is difficult to define. It is difficult to measure. And as a result, it is not simple to operationalize.

Operationalising social capital

In order to consciously increase social capital, we need to know first, what it looks like, and second, how to build it. In a seminal article in 1986, Pierre Bourdieu argued that social capital is reproduced through constant opportunities for ‘legitimate exchanges’ or opportunities for contact between the members of a network. Social capital is not something that just happens, or that can be neglected: “The reproduction of social capital presupposes an unceasing effort of sociability, a continuous series of exchanges.”3

This ‘series of exchanges’, in a healthcare organization, incorporates both formal contacts –patient conferences, ward rounds– and informal. There is a space for the apparently frivolous, creating opportunities for team members to socialise that are not focused on work. But it is not enough to bring healthcare staff together and hope that higher levels of social capital will automatically result.

In the next section we lay out what we identify as the five features of a healthcare organization with high social capital, and indicate how each of these five features may be built. In the final section we propose a methodology for developing a strategy to increase social capital in a healthcare organization.

Building social capital

The literature suggests five features of a healthcare organization with high social capital: trust, reciprocity, shared values, shared norms and openness (other, often overlapping features could be identified, but these seem to us to lie at the core). More detail on how to build these is in Table 1.


Features of social capital

Trust: Healthcare at its core is founded on trust: the trust of patients for doctors, between members of a surgical team, or between social workers and hospital staff. The teamwork necessary to treat and heal a patient demands trust, which can only be built through commitment from both sides, to keep trusting and to be worthy of trust.

Key to this is communication, which can set expectations and provide assurance of good faith even if events do not turn out as planned6,16. Organizational behaviours of honesty and of commitment to staff need to be modelled by leadership first, if they are to filter down through the organization. Healthcare organizations which are characterised by higher trust levels may be able to simplify administrative procedures, prioritise meetings around the needs of patients rather than organizational bureaucracy, delegate higher levels of responsibility so that all staff can work at the top of their licence, and simplify the flow of funds.. In short, trusting organizations have the potential to be more efficient, and possibly more effective.

Reciprocity: The willingness to help out another individual or team cannot be sustainable if it is always one-sided; social capital cannot be built on exploitation 18. Reciprocity often appears at the informal level, with healthcare organizations thriving on a complex web of favours and help given between individuals. But it can also be more formally built as an organizational principle: for example, organizations with a “Physicians’ Compact” may have clear understanding of the organization’s and physicians’ obligations to each other. In the UK, the entire health system is underpinned by the NHS Constitution, which lays out what patients are entitled to and what they are expected to do in return. Organizational behaviours of a willingness to share expertise and to learn from others are important to this.

Shared values: One of the most powerful motivators for people to work together is the belief in a shared set of values and a common purpose. Healthcare organizations sometimes assume that all their staff share the motive of caring for patients, but in fact motives to work in healthcare can vary from the desire to excel at a technical skill to a focus on earning a high salary19. Shared values can be built in many ways, but if it is to genuinely motivate staff a shared purpose needs to speak to the heart as well as the brain20. Making a healthcare organization’s priorities clear - whether it be that the organization puts “Patients First”, or that it aims to improve the value of healthcare, can provide both clarity of purpose and motivation.


Shared norms: Large organizations often struggle with the diversity of approaches within them. Healthcare organizations are perhaps more prone to this than most, where every clinician may have their preferred way of doing things. Shared norms can be built through establishing shared processes, for example through shared electronic health records. Standardised behaviours through the use of checklists. Change towards shared norms for the organization can improve performance as well as building operation between healthcare staff21

Openness: Healthcare comes with an inherent level of risk, which may be increased by innovation. Healthcare organizations need to find a fair balance between accepting a reasonable level of risk, and sanctions where appropriate against careless or inappropriate behaviour. Key to finding this balance is establishing fair, transparent, and above all consistent mechanisms to deal with medical errors. Healthcare organizations who offer the best and brightest staff the chance to make improvements, and who challenge teams to improve, are more likely to both keep and motivate their staff.

Many of the features above are components of good leadership; and as such they are often taken for granted or not made conscious. But to consign social capital to the ‘nice to have’ box misses its importance. We believe that health care organizations that explicitly recognize the value of building social capital will be rewarded with better performance.

Creating a strategy to build social capital

This list draws on the toolkit for building social capital in communities developed by the Kennedy School of Government at Harvard22, as well as the wider literature.

1. Define your objective(s): Building social capital can (for example) improve staff engagement or morale; deepen patient engagement; improve communication between care teams; strengthen an organization’s negotiating position in the wider health economy. Identify which of these is your organization’s key priority.

2. Identify your starting point: Key to designing the optimal approach is to identify what level of social capital exists in the organization at the moment, particularly as it relates to your objectives.

a. What is the overall level of social capital in the healthcare organization – is there a general culture of trust, openness and reciprocity? Or is the organization riven by internal rivalries and disputes?

b. Are there particular problem areas? This diagnosis requires an understanding of the complex existing networks within the organization.

Social capital may need to be (re)built at any of these at levels: 

In-group - relationships between members of a particular team;

Intra-group – relationships between teams, wards, departments or faculties;

Organizational – relationships between leadership and staff; 9

Systemic: the relationship and networks between organizations, eg between a hospital and its provider network or its competitors;

Patients: relationships with patients are often built at the level of individual clinicians, but the organization as a whole may need to focus on relationships with its patient base;

c. What strengths does the healthcare organization already possess that you can build on? Are there informal staff networks or groups that you could support?

3. Design the interventions that will achieve the objectives. The interventions will depend on what the healthcare organization’s objectives are; what the existing problems are; what strengths the organization currently has; and which individuals or teams are best placed to help solve the problem. Some examples are in the table below.

In conclusion, the imperative to organize healthcare around patients (as opposed to transactions) means that health care personnel must work together with new levels of effectiveness and efficiency. Healthcare organizations thus need to build social capital with the same focus and discipline that they have applied to financial capital in the past.

Table 1: strategies for building social capital

Features of a high                                                   Strategies to build the features
social capital
organization



Trust  - Demonstrate trust in staff by delegating and allowing staff to work to the top of their licence:

- In order to receive trust a healthcare organization first needs to demonstrate trust in its staff. Placing trust in more junior staff can improve their motivation and free up the time of more senior staff enabling the whole team to work at the top of its licence.


Be honest in communication:

- Keep staff and patients informed of changes and situations affecting them. If the organization is consulting on an issue, make sure that the consultation is genuine. If a situation changes and the leadership cannot deliver on a commitment, say why.

- Be clear where it is effective to use electronic and online communications to share information between doctors and patients as well as between clinicians, and where face to face is required.


Build opportunities for interaction:

- Redesign physical space: build in meeting spaces for informal as well as formal communications and information exchange. The redesign of physical space encouraged by LEAN and similar methodologies needs to be broad enough to include this.

- Encourage / support existing informal staff groups or networks and non-work-related socialising such as team volunteering. Move staff between teams: Reduce silo working and strengthen bridging social capital by creating an expectation that staff will undertake placements when possible. Encourage specialists to work between locations.



Reciprocity - Establish formal statements of responsibility and reciprocity

- Documents such as a ‘Physician’s Charter’ or a ‘Constitution’ for patients can help to ensure that staff and patients are aware both of their rights and responsibilities.

Demonstrate commitment to the individual:

- Invest in training and development opportunities for staff. Particularly in hierarchical structures, loyalty must demonstrably go both ways.

Align incentives for working together:

- Ensure that working together is recognised and rewarded

- Ensure that funding structures reward rather than punishing joint working


Shared Values - Make the priorities of the organization clear

- Develop and publicise shared statements of the organization’s mission. The values and mission should be short, clear and 12memorable.

Engage staff in developing statements of shared values.

- Work with staff to ensure that their motivations and priorities are reflected, wherever possible, in the organization’s statement of values

Ensure that shared values are ‘lived’ by the organization:

- Statements of values should be restated implicitly and/or explicitly in interactions between groups and within groups.

- Senior leadership should model behaviours


Use powerful stories.

- Emotional engagement around shared values is more powerful than purely intellectual agreement. Stories about successes (or failures) in patient care can motivate an organization while reaffirming its values.


Shared norms Establish shared processes:

- Ensure consistency in processes for patient care, allowing optimal processes to be disseminated and embedded, and reducing errors.

- Establish a shared language between teams and disciplines, reducing misunderstandings and aiding communication

- Ensure consistency in measuring performance across an organization and between organizations, allowing for benchmarking.

- Bring staff from different teams together to remove unnecessary duplication: where different parts of an organizations do not trust each other, procedures such as tests may be duplicated. Developing shared processes can reduce costs.

- Ensure that basic introductions and pre-briefings are in place for teams (e.g. surgical teams) who have not worked together before


Develop standardised procedures

- Develop checklists and standardised processes: some variations in clinical practice will be inevitable based on the needs of patients, but normalising effective, cost-effective approaches for standard procedures can increase quality. Checklists developed jointly between teams are more likely to be accepted and adopted.


Openness Assess errors in context.

- Develop a culture of appropriate forgiveness rather than a punitive approach to error. One strategy is to use an Incident Decision Tree, taking into account factors such as intent and whether an equivalently trained person could have erred in a similar manner


References

(1) Putnam, R. D.: Commentary: ‘Health by association’: some comments. International journal of epidemiology 2004, 33, 667-671.

(2) OECD "The Well-Being of Nations: The Role of Human & Social Capital," Organization for Economic Co-operation and Development, 2001.

(3) Bourdieu, P.: The Forms of Capital. In Handbook of Theory and Research for the Sociology of Education; Richardson, J., Ed.; Greenwood: New York, 1986; pp 241-258.

(4) Dolfsma, W.; Dannreuther, C.: Subjects and boundaries: contesting social capital-based policies in Developing Countries. Journal of Economic Issues 2003, 37, 405-413.

(5) Aldridge, S.; Halpern, D.; Fitzpatrick, S. "Social Capital: A Discussion Paper," Performance and Innovation Unit, 2002.

(6) Putnam, R.: Bowling Alone: The Colllapse and Revival of American Community Simon and Schuster: New York, 2000.

(7) Narayan, D.: Bonds and bridges: social capital and poverty. In Social Capital and Economic Development: Well-being in Developing Countries; Ramaswamy, S., Ed.; Edward Elgar: Cheltenham, 2002.

(8) de Souza Briggs, X.: Doing Democracy Up-Close: Culture, Power, and Communication in Community Building. Journal of Planning Education and Research 1998, 18, 1-13.

(9) Hsu, C. P.; Chang, C. W.; Huang, H. C.; Chiang, C. Y.: The relationships among social capital, organizational commitment and customer-oriented prosocial behaviour of hospital nurses. Journal of clinical nursing 2011, 20, 1383-92.

(10) Gloede, T. D.; Hammer, A.; Ommen, O.; Ernstmann, N.; Pfaff, H.: Is social capital as perceived by the medical director associated with coordination among hospital staff? A nationwide survey in German hospitals. Journal of interprofessional care 2012.

(11) Cunningham, F. C.; Ranmuthugala, G.; Plumb, J.; Georgiou, A.; Westbrook, J. I.; Braithwaite, J.: Health professional networks as a vector for improving healthcare quality and safety: a systematic review. BMJ quality & safety 2012, 21, 239-49.

(12) Brunetto, Y.; Farr-Wharton R.; Shacklock, K.: The impact of supervisor-subordinate relationships on nurses' ability to solve workplace problems: implications for their commitment to the organization. Advances in health care management 2011, 10, 215-37.

(13) Hopkins, M. M.; O'Neil, D. A.; FitzSimons, K.; Bailin, P. L.; Stoller, J. K.: Leadership and organization development in health-care: lessons from the Cleveland Clinic. Advances in health care management 2011, 10, 151-65.

(14) Mascia, D.; Cicchetti, A.: Physician social capital and the reported adoption of evidence-based medicine: exploring the role of structural holes. Social science & medicine (1982) 2011, 72, 798-805. (15) Safran, D. G.; Miller, W.; Beckman, H.: Organizational dimensions of relationship-centered care: theory, evidence, and practice. Journal of general internal medicine 2006, 21 Suppl 1, S9-15.

(16) Cohen, D.; Prusak, L.: In Good Company: How Social Capital Makes Organizations Work; Harvard Business Press, 2011.

(17) Nahapiet, J.; Ghoshal, S.: Social Capital, Intellectual Capital, and the Organizational Advantage. The Academy of Management Review 1998, Vol. 23, pp. 242-266.

(18) Jain, S. H.; Goyal, R.; Fox, S.; Shrank, W. H.: Bowling alone, healing together: the role of social capital in delivery reform. The American journal of managed care 2012, 18, e209-11.

(19) Medscape: Medscape Physician Compensation Report 2013. 2013; Vol. 2013.

(20) Hammer, A.; Ommen, O.; Rottger, J.; Pfaff, H.: The relationship between transformational leadership and social capital in hospitals--a survey of medical directors of all German hospitals. Journal of public health management and practice : JPHMP 2012, 18, 175-80.

(21) Tsasis, P.; Evans, J. M.; Forrest, D.; Jones, R. K.: Outcome mapping for health system integration. Journal of multidisciplinary healthcare 2013, 6, 99-107.

(22) Sander, T. H.; Lowney, K. "Social Capital-Building Toolkit (Version 1.2)," John F. Kennedy School of Government, Harvard, 2006.