Cooperation: The Foundation of Improvement

Cooperation-working together to produce mutual benefit or attain a common purpose-is almost inseparable from the quest for improvement. Although the case for cooperation can be made on ethical grounds, neither the motivation for nor the effects of cooperation need to be interpreted solely in terms of altruism. Cooperation can be a shrewd and pragmatic strategy for accomplishing personal goals in an interdependent system. Many disciplines have made cooperation an object of study; these include anthropology; social psychology [1]; genetics [2]; biology [3]; mathematics; game theory [4]; linguistics; operations research; economics [5-7]; and, of course, moral and rational philosophy. Earlier papers in this series have explored the conceptual roots of modern approaches to improvement, which lie in systems theory [8]. A system is a collection of interdependent elements that interact to achieve a common purpose. Performance-measured in health care by such yardsticks as health outcomes, complication rates, waiting times, and patient satisfaction-is a system property inherent in the work of physicians. To improve systems, we must usually attend first and foremost to interactions. Among humans, better interaction is almost synonymous with better cooperation. Those who aim to improve health care must be students and practitioners of cooperation, not because it is nice (although it often is nice) but rather because mutual aims require it. Actually, cooperation is not always essential for improvement. The degree of interdependence in the system makes a difference. Take sports as an example. For a bowling team, achieving the highest score depends on every person's doing his or her best. Cooperation, except perhaps in exchanging tips, is not the primary issue in successful bowling. But a basketball team courts failure if every player's primary goal is simply to score the most possible personal points. Playmakers and rebounders make essential contributions to team success. More often than not, a balanced team that passes well will beat an equally talented team full of players who hog the ball. Health care has its bowling events, to be sure, especially when the lens zooms in on the individual encounter. Alone in the examination room with a grieving patient, the physician does his or her best for the patient primarily through individual skill and compassion. But zoom out again, and the basketball analogy seems stronger. A single physician managing patients with chronic asthma may have difficulty developing systems that prevent exacerbations by reaching into patients' homes or training patients to monitor their own pulmonary function. But embed that physician in a group practice or a sound managed care organization, and responsive, willing, cooperative others-such as managers, nurses, pharmacists, and health educators-may be able to configure supports that help everyone, including the physician, the patients, their families-even payers-all at the same time. Scientific Foundations for Successful Cooperation A review of modern theories of the foundations, uses, and problems of cooperation is beyond the scope of this paper, but a few examples suggest the richness of the scientific terrain for potential students of the topic. Ronald Coase, from the University of Chicago, won the Nobel Prize in Economics in 1991, largely for theoretical work on transaction costs closely related to normative theories of cooperation. In one of his most influential papers [9], Coase relates the story of a railroad with a right-of-way through a farmer's fields. As trains crossed the field, they spewed sparks, damaging crops close to the tracks. Coase asserted that the usual social approach to the problem, a rights-based search involving lawyers; lawsuits; litigation; and, probably, an enforced remedy under which the railroad might have to install equipment to suppress the sparks would not produce the solution with the lowest cost to society. Instead, if the railroad and the farmer could bargain easily, they would probably discover a far less costly solution; for example, the farmer might agree not to grow crops within reach of the sparks if the railroad would pay the farmer for profits thereby lost. Coase's vignette easily brings to mind any number of problems in health care (such as neurosurgeons and orthopedists arguing for operating room time) that often lead to fairness solutions (equal time) or resource investments (building more operating rooms) instead of solutions that are optimal for the system as a whole. We argue that this is evidence of a low level of cooperation between the specialties. Coase asserts that leadership in organizations can provide a context for purpose-based conversation or bargaining instead of reliance on more costly, rights-based solutions. Reinertsen [10] describes the physician's role in providing this type of leadership and methods for executing those leadership responsibilities. However, it is difficult to identify someone who might provide that leadership. Hiatt [11] recognizes that some aspects of health care lack obvious leadership in fostering cooperation. In particular, he refers to three kinds of conflict over the use of resources for medical practices: conflict between the interest of the individual and the interest of society, conflict over whether a medical procedure provides value, and conflict between preventive and curative practices. Coase shows that lack of leadership can be expensive. If this leadership is missing, is cooperation impossible? This question was addressed by Robert Axelrod, from the University of Michigan, who extensively explored the famous game theory problem, the Prisoner's Dilemma, in The Evolution of Cooperation [12]. Axelrod was primarily concerned with cooperation as a self-initiated strategy for an individual person working in a system rather than with the leadership-initiated cooperation explored by Coase. His work gives hope that the health care system can be positively affected by physicians skilled in cooperative behaviors. In the Prisoner's Dilemma (Table 1), two players each face a matrix defining the consequences of their independent, blinded choices to cooperate or to defect. If one player cooperates while the other defects, the defector wins. If both defect, both lose. If both cooperate, both win, but not as much as a lone defector does. Table 1. The Prisoner's Dilemma In the short run, defection is the only rational choice, assuming that each person seeks only to maximize his or her gains independently. To see why, assume that you are player 2 and work out the consequences of your own actions in a one-cycle Prisoner's Dilemma game. No matter what player 1 does, you are better off defecting. The game gets interesting and the ideal strategy gets less obvious when the game is continual or has an uncertain future. If player 2 is shrewd or powerful enough to maintain the result in the upper right-hand cell, only altruism would motivate player 2 to move to another cell. (Perhaps physicians and hospitals were in player 2's position in the past, when society was willing to pay double-digit annual percentage increases in health care costs.) However, continual refusal to cooperate usually leads to a system that equilibrates to the bottom right-hand cell, producing unsatisfactory results both for the two persons playing and for the system as a whole, like wasteful hospital construction in an over-bedded city. Axelrod invited game theorists, economists, and mathematicians to write computer programs to play Prisoner's Dilemma, and when all entries played all other entries in a series of games, one strategy dominated. It did not win every match, but it came out ahead on the average across all matches. Axelrod dubbed the winning strategy tit-for-tat, and its algorithm consisted of only two rules: cooperate on the first move and, thereafter, do what your opponent did on the previous move. In a similar vein, Fisher, Ury, and Patton [13], along with their colleagues in the Harvard Negotiation Project, have spent two decades developing and refining teachable approaches to what they term principled negotiation, strategies of conflict resolution. They aim to provide methods that can help parties invent new solutions and move beyond the static, constrained payoffs of the Prisoner's Dilemma. Their work emphasizes the importance of relationship in the quest for good solutions-best of all, win-win outcomes to disagreements initially thought to have only win-lose possibilities. Applications of research findings on cooperation have resulted in improved safety, reliability, and effectiveness in many industries. Aviation safety experts, for example, have long known that communication failures account for more than three fourths of commercial airline accidents and that sociological barriers to communicating crucial information against the authority gradient (for example, from a navigator to a pilot) often lie at the root of these communication failures [14]. Building on this knowledge, the aviation industry has invested heavily in training crews (and especially their highest-status members, pilots) to ensure highly cooperative norms and behaviors regarding mutual assistance and exchange of information as mainstays of safety. This field is known as cockpit resource management [15]. Although extrapolation of technical methods from one industry to another requires caution, researchers in simulated operating rooms have found the same communication hazards found in aircraft cockpits. They suggest that cockpit resource management techniques may have as much promise in health care as in aviation [16]. Other writers and researchers have made equally important contributions to our understanding of the uses and methods of cooperation in health care and in other industries. We summarize these few here not to give them preeminence but rather to support our assertion that cooperation is a proper subject for study b