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Academia and the Profession |

Cooperation: The Foundation of Improvement

Terry P. Clemmer, MD; Vicki J. Spuhler, RN, MSN; Donald M. Berwick, MD, MPP; and Thomas W. Nolan, PhD
[+] Article and Author Information

From University of Utah School of Medicine and LDS Hospital, Salt Lake City, Utah; Institute for Health Care Improvement, Boston, Massachusetts; and Associates in Process Improvement, Silver Spring, Maryland. Requests for Reprints: Terry P. Clemmer, MD, Critical Care Medicine, LDS Hospital, 8th Avenue and C Street, Salt Lake City, UT 84143; e-mail: tclemme@ihc.com. Current Author Addresses: Dr. Clemmer: Critical Care Medicine, LDS Hospital, 8th Avenue and C Street, Salt Lake City, UT 84143.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1998;128(12_Part_1):1004-1009. doi:10.7326/0003-4819-128-12_Part_1-199806150-00008
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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. Earlier papers in this series have explored the conceptual roots of modern approaches to improvement, which lie in systems theory. To improve systems, we must usually attend first and foremost to interactions. Among humans, “better interaction” is almost synonymous with “better cooperation.” Physicians have ample opportunities and, indeed, an obligation to cooperate with other physicians in the same or different specialties, with nurses and other clinical workers, with administrators, and with patients and families.

Many intellectual disciplines have made cooperation an object of study.These include anthropology; social psychology; genetics; biology; mathematics; game theory; linguistics; operations research; economics; and, of course, moral and rational philosophy. Scientifically grounded methods to enhance cooperation include developing a shared purpose; creating an open, safe environment; including all who share a common purpose and encouraging diverse viewpoints; negotiating agreement; and insisting on fairness and equity in the application of rules. These methods apply at the organizational level and at the level of the individual physician. This paper describes the application of these methods at the organizational level and focuses on one especially successful example of system-level cooperation in a care delivery site where interactions matter a great deal: the modern intensive care unit.

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