Dealing with Conflict in Health Care:The Next Dimension of Team Training

Scott Ellner, DO, MPH, FACS

Vice Chairman of SurgerySaint Francis Hospital and Medical Center

Hartford, ConnecticutJUNE 27, 2013

Blame and Shame

Identify Culture

• Communication

• Behavior

• Rituals

• Tolerance

OR Safety Attitudes Questionnaire - SAQ

12. In the OR, it is difficult to discuss errors. 1 2 3 4 5

SAQ Participants

N=165

Dimensions and Service Line Comparison

2009:

Service Line (responses)/Dimension (AHRQ Benchmark)

Hospital Handoffs and Transitions (38)

Staffing (49)

Feedback and Communication About Error (60)

Teamwork WITHIN units (77)

Manager Expectations & Actions P romoting Safety (72)

Organizational Learning - Cont. Improvement (68)

Management Support for Patient Safety (65)

Overall Perceptions of Safety (56)

Communication Openness (60)

Teamwork Across Units (50)

Nonpunitive Response to Error (38)

Behavioral Health (99) 25 54 62 70 77 71 76 60 51 49 38Rehab (53) 20 52 58 83 78 70 69 54 72 48 54Women & Infants (19) 33 46 48 65 63 61 57 58 46 37 29Oncology (36) 31 62 52 70 59 68 45 46 57 28 34Cardiovascular (82) 49 46 57 81 63 63 50 56 56 61 44Surgery (165) 37 48 48 72 64 60 56 54 49 35 36CJ RI (70) 44 41 37 64 68 61 50 48 58 28 46Critical Care (84) 38 60 67 93 73 72 50 63 66 40 28Primary Care (34) 39 38 33 64 62 57 35 40 53 36 42Medicine (52) 42 70 62 79 71 58 62 74 64 54 55ED (7) 23 20 10 37 25 50 19 13 29 24 29

Launch of Team Training

Team Training Tool• Session 1 – Crucial

Conversations• Session 2 – Getting What You

Want: Communication Strategies That Help You Get What You Need • Session 3 – When the Going

Gets Tough: Achieving a Positive Outcome

Why Team Training?

Next Steps

Presentation Objectives

• Describe the root of conflict

• Understand how to reframe during negotiations

• Learn the Walk in the Woods Technique

Conflict in Health Care

Recipe for Conflict

?Ambiguity

Complexity

Vagueness

Competition

Hierarchy

High stress

Recipe for Conflict

CONSEQUENCES

Mistrust Disruptive Behavior

Changes in Policy

Is All Conflict Bad?

Power and Negotiation

Positional Bargaining

Interest-Based Negotiation

Positional Bargaining

Walk in the Woods

A Path to Interest-Based Negotiation

Geneva, Switzerland 1982

Step by Step Approach

Problem

Self-Interests

Enlarged Interests

Enlightened Interests

Aligned Interests

Solution

Stakeholders

Self-Interests (Phase 1)Problem

What Gains can come from this meeting?

Building Confidence(Trust)

Active Listening

Constructive and safe zone expression of interests

Self-Interests

Productive Conversation Recognition of the complexity of the Problem

Enlarged Interests (Phase 2)

Agreements Disagreements1) Hire new staff 1) Reduce benefits 2) Measure quality

2)

REFRAMING

Self

Enlarged

Shared Mental Model

Enlarged Interests

Enlarged Interests

How can we REFRAME to avoid this scenario?

Enlarged Interests

What is it we agree upon?Identify and interpret each choice

Encourage questions to generate discussion

REFRAMING

Learning StepsSelf Interests Enlarged Interests

Investment

Physical

Emotional

Spiritual

Financial

Unlearning

New Learning

Enlightened Interests (Phase 3)

Imagine if….?

Enlightened Interests

Enlightened Interests

No Commitment Zone

Encourage open thinking and discussion

HumorCreativityExploration of ideas

Spurring momentum

Enlightened Interests

Ranking of ideas

Examine the enlightened list

What is agreed upon?

Is it feasible?

Ease of implementation?

6

Ease of Implementation

Feas

ibili

ty 3

2

1

Enlightened Interests

The Capacity to Imagine

Deal Makers Deal Breakers

IDEAS IDEAS

Further Negotiation3 1

2

Aligned Interests (Phase 4)

Redefining Success

I We

Overlapping Interests

Mesh

Alignment

Aligned Interests

Creating Value for All Parties

…..When YOU Succeed, then WE Succeed

When I Succeed, then YOU Succeed…..

Each party achieves a recognizable gain

Aligned Interests

Fair Equitable

Meets the Test of Time

Collaborative

Aligned Interests

Record and Sign the Agreement

Celebrate the Agreement

Action Steps

Enlightened Interests Aligned Interests

Negotiation from a Uni-dimensional approach

Action Steps

To a multi-dimensional approach

Dimensions and Service Line Comparison2009:

2013:

Service Line (responses)/Dimension (AHRQ Benchmark)

Hospital Handoffs and Transitions (40)

Staffing (53)

Feedback and Communication About Error (62)

Teamwork WITHIN units (78)

Manager Expectations & Actions P romoting Safety (72)

Organizational Learning - Cont. Improvement (71)

Management Support for Patient Safety (68)

Overall Perceptions of Safety (61)

Communication Openness (59)

Teamwork Across Units (53)

Nonpunitive Response to Error (39)

Behavioral Health (84) 47 55 62 77 81 70 64 66 63 55 54Rehab (86) 28 50 46 69 71 63 72 66 52 59 51Women & Infants (156) 47 76 64 92 84 80 77 75 68 56 49Oncology (92) 35 48 51 79 66 72 60 58 61 49 47Cardiovascular (161) 45 54 73 84 87 81 70 70 68 59 42Surgery (444) 36 58 56 75 72 73 69 68 61 50 40CJ R I (72) 51 67 67 77 78 84 81 81 57 50 39Critical Care (148) 46 49 62 86 74 76 58 62 61 56 38Primary Care (106) 32 47 43 76 70 54 66 63 58 52 36Medicine (166) 33 39 50 69 59 59 54 48 47 46 35ED (94) 29 23 48 69 65 58 46 34 42 35 20

Below the benchmark (below 90%)Caution (>90% and <95%)

Service Line (responses)/Dimension (AHRQ Benchmark)

Hospital Handoffs and Transitions (38)

Staffing (49)

Feedback and Communication About Error (60)

Teamwork WITHIN units (77)

Manager Expectations & Actions P romoting Safety (72)

Organizational Learning - Cont. Improvement (68)

Management Support for Patient Safety (65)

Overall Perceptions of Safety (56)

Communication Openness (60)

Teamwork Across Units (50)

Nonpunitive Response to Error (38)

Behavioral Health (99) 25 54 62 70 77 71 76 60 51 49 38Rehab (53) 20 52 58 83 78 70 69 54 72 48 54Women & Infants (19) 33 46 48 65 63 61 57 58 46 37 29Oncology (36) 31 62 52 70 59 68 45 46 57 28 34Cardiovascular (82) 49 46 57 81 63 63 50 56 56 61 44Surgery (165) 37 48 48 72 64 60 56 54 49 35 36CJ RI (70) 44 41 37 64 68 61 50 48 58 28 46Critical Care (84) 38 60 67 93 73 72 50 63 66 40 28Primary Care (34) 39 38 33 64 62 57 35 40 53 36 42Medicine (52) 42 70 62 79 71 58 62 74 64 54 55ED (7) 23 20 10 37 25 50 19 13 29 24 29

Summary

Conflict occurs everyday in everyway

Self Interests = Presenting each party’s interestsEnlarged Interests = Reframing occurs Enlightened Interests = Exploring the optionsAligned Interests = Agreeing on recognizable gains

The Walk in the Woods technique is a valuable strategy to use when negotiating conflict

Thank You

Scott Ellner, DO, MPH, FACSsce107@mail.harvard.edu