Addressing chronic conflict and problematic behaviors in a group practiceAnthony L. Suchman, MD, MA Jody Hoffer Gittell, PhD Elsie Mainali, MD, PhD

Healthcare Consultancy, McArdle Ramerman Center, Rochester, NY Heller School for Social Policy and Management, Brandeis University, Waltham, MA Virginia Beach, VA

Background

Current Condition

Analysis Targets

Implementation

Results/Follow-up

In a subspecialty intensive care unit with 60 hospital staff members and a 5 person physician group, conflict between the physicians was compromising quality by disrupting the continuity of care, hindering communication and creating a tense work environment.

• shift-work mentality (“you just do your work and go home”); collaborative interaction limited to sign-out rounds; doctors want more cohesiveness• perception of “immature” or “petty” behaviors on the part of others, dismissed by some as just “personality differences”• little awareness of negative impact on quality or the negative perceptions of the practice throughout the hospital• conflict-averse leader, no systematic accountability; doctors want stronger leadership• new practice director hired from outside, about to take over

Overall RCS scores

Phys Nurses (day)

Nurses (night)

RT (day)

RT (night)

OT/ PT

Unit Sec’ty

Case Mgrs

Nurse Mgrs

Overall

Physician 3.70 4.02 3.83 3.89 3.67 3.65 3.56 3.58 3.36 3.71

Nurses (day)

3.87 4.42 4.30 4.15 4.08 4.20 4.29 4.05 3.70 4.04

Nurses(night)

3.59 4.18 4.43 4.09 3.95 2.40 4.23 3.14 4.08 3.83

OT/PT 3.28 4.33 3.50 2.81 3.21 4.57 3.90 4.10 3.38 3.51

Unit Sec’y 3.77 4.43 4.29 3.33 3.33 3.43 4.57 3.57 3.86 3.82

Case Mgrs 3.80 4.25 3.33 3.93 2.61 4.00 4.36 4.57 4.07 3.86

Nurse Mgrs

3.09 3.86 3.86 3.29 3.29 3.14 3.57 2.86 4.57 3.37

Overall 3.73 4.27 4.17 3.95 3.80 3.85 4.14 3.84 3.81 3.88

Dimension of Relational Coordination

Avg - all work

groups

Phys1 Phys2 Phys3 Phys4 Phys5

Frequent Communication

4.47 3.92 4.62 4.57 3.74 4.72

Timely Communication

3.81 3.75 4.00 3.77 3.22 3.85

Accurate Communication

3.97 4.03 4.14 3.85 3.69 3.97

Problem-solving Communication

3.63 2.76 3.89 3.61 3.33 3.41

Shared Goals 3.85 3.50 3.73 3.77 3.36 3.74

Shared Knowledge

3.53 3.61 3.62 3.54 3.31 3.53

Mutual Respect 3.60 3.03 3.65 3.41 2.97 3.53

Overall Relational Coordination

3.88 3.58 3.98 3.84 3.44 3.87

Number of Respondents

39 38 39 37 39 36

Cronbach’s Alpha

.78 .79 .52 .76 .83 .74

Relational Coordination survey scores:

No collective identity (I >> we) Shared purpose, vision and goalsInadequate time together as a practice to develop connections and discuss clinical approaches

Practice meets periodically to review results, develop pathways and conduct quality improvement projects

Poor insight about how others see self and practice Accurate individual and collective self-assessment based on dataInadequate communication skills to work with difference

Skills for emotional self-management and managing difference as a resource

Extreme individual autonomy Interdependent autonomy; co-created individual performance goalsConflict-averse, disengaged leadership Effective leadership to create cohesiveness, alignment and accountability

360 feedback for individuals and practice based on interviews and RCSCoaching for practice leader

Individual feedback reports

Practice retreat for teambuilding, skills development and dialog to create collective vision and expectations

1:1 meetings with director q 3 wks to develop and track individual performance goals

Phys Nurses (day)

Nurses (night)

RT (day)

RT (night)

OT/ PT

Unit Sec’ty

Case Mgrs

Nurse Mgrs

Overall

Physician(6, 5)

3.704.22

4.023.86

3.833.83

3.894.03

3.673.89

3.653.49

3.563.83

3.583.71

3.363.40

3.713.92

Nurses (day)(12, 10)

3.873.97

4.424.30

4.304.20

4.153.87

4.083.42

4.204.07

4.293.97

4.053.82

3.702.85

4.043.88

Nurses(night)(12, 6)

3.593.90

4.184.04

4.434.39

4.093.82

3.954.07

2.403.43

4.234.11

3.143.82

4.084.18

3.833.99

OT/PT(3, 0)

3.28NA

4.33NA

3.50NA

2.81NA

3.21NA

4.57NA

3.90NA

4.10NA

3.38NA

3.51NA

Unit Sec(1, 1)

3.774.00

4.434.00

4.294.00

3.334.00

3.334.00

3.434.00

4.574.14

3.574.14

3.864.00

3.824.02

Case Mgrs(2, 0)

3.80NA

4.25NA

3.33NA

3.93NA

2.61NA

4.00NA

4.36NA

4.57NA

4.07NA

3.86NA

Nurse Mgrs(1, 1)

3.093.69

3.864.14

3.864.14

3.293.71

3.293.71

3.143.71

3.574.14

2.863.71

4.574.17

3.373.84

Overall(39, 26)

3.734.10

4.274.19

4.174.19

3.953.98

3.803.87

3.853.90

4.144.07

3.843.86

3.813.55

3.884.04

• One physician was unable to meet individual performance goals and left within 2 months.• Each of the other 4 physicians improved their individual RCS scores.• The practice began to meet weekly, created clinical pathways and started QI projects.• At a follow-up retreat 6 months after the first one the practice made plans to improve service to internal customers and practiced the necessary communication skills.• The RCS shows potential as a feedback tool and demonstrates sensitivity for tracking longitudinal changes in individual and group performance.

Themes from preliminary interviews: