managing conflict on health care teams -...

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Managing Conflict on Health

Care TeamsIHI 12-8-14

Nan Cochran, MD

Neil Baker, MD

Calvin Chou, MD, PhD

Objectives

1. Explain how to build relationships while negotiating

2. Define differences between interests and positions

3. Identify ways to separate fact from assumptions and

stories

4. Practice identifying and using emotions during conflict

5. Demonstrate how to negotiate in the face of differences in

authority

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Gawande, A. Cowboys and Pit Crews The New Yorker, 2011

• Staffing on hospital teams to care for one patient

1970’s 2.5 FTE

1990’s 15 FTE

• Increased focus on efficiency

• Vast regulatory requirements

“Medicine’s complexity has exceeded our individual capabilities as doctors.”

Increased complexity in financing

and delivery of care

Resolving conflict to build

collaboration• Inevitable - we negotiate our

differences every day

• If poorly managed or avoided, can

reduce productivity, undermine

trust

• If viewed as opportunity,

encourages constructive expression

of differences so they can be

acknowledged, addressed

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Goal In Conflict – avoid disruptive

behavior

“ interferes with patient care or adversely affects the health care team’s ability to work effectively. It encompasses behavior that adversely affects morale, focus and concentration, collaboration, and communication and information transfer, all of which can lead to substandard patient care.”

American Medical Association Council on Ethical and Judicial Affairs. Physicians With

Disruptive Behavior. Chicago, IL: American Medical Association; 2000. Report 2-A-00.

• Jt Commission ~ 70% sentinel events traced to a problem with

communication

• >70% medical errors attributable to dysfunctional team dynamics

• Physician survey (n= 840):

- More than 70% observed disruptive MD behavior at

least monthly, 10% daily

- 99% stated conflict negatively impacted pt care1

MacDonald O. Disruptive Physician Behavior. American College of Physician Executives. May 2011.

Mitchell,R. Health Care Manage Rev, 2014, 39(1), 1Y9

How Common is Disruptive Behavior?

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Downstream Effects of Poorly

Managed Conflict• Decreased safety – more adverse events

• Poor teamwork

• Lower quality of care

• Higher costs of care

• Poor job satisfaction, increased turnover

• Patient dissatisfaction

• Higher dissatisfaction among trainees

What does disruptive behavior look like?

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JCJ on Quality and Patient Safety, 8-08

How often do disruptive

behaviors impact S and Q?• 102 Hospitals: 944 physicians, 2846 nurses, 40 admin execs

• 77% had witnessed disruptive behavior in MDs

• % stated impact was sometimes, frequent, constant

Rosenstein AH Jt Comm J Qual Patient Saf. 2008;34(8):464-471.

Impact disruptive behavior on

workplace, teamworkn = 944 physicians, 2846 nurses, 40 administrative

executives, and 100 others in 102 hospitals

Rosenstein AH Jt Comm J Qual Patient Saf. 2008;34(8):464-471.

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I experienced conflict that I found

difficult in the last month

A. True

B. False

I experienced conflict that could have

compromised patient care in the last

month

A. True

B. False

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Why is conflict so hard?

Reactivity

RelationalSubstantive

Distrust

Dislike

Personality differences

Power differentials

Differing styles

Strategy

Goals

Tasks

Roles

Protocols

Sources of conflict

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Relational Substantive

To trust, like,

or avoid each other

Create winners

and losers

To avoid interaction or

to assure agreement

To win

Goals: flight

Goals: fight

Flight or fight

Beyond flight or fight

Created by Neil Baker M.D. for AACH

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Fisher et al Getting to Yes: Negotiating Agreement Without Giving In 2014

Build relationships that can

manage differences well.

Create wise solutions

built on shared interests.

A third way

Two simultaneous goals

MethodsSeparate the people from the problem.

Build relationships as you negotiate. Focus on interests, not positions.

Caution! Flawed assumption:Emotions don’’’’t matter.

Emotions--bundles of thoughts, impulses, feelings, and bodily sensations.

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Watch for clues

Stuck

Angry

Defeated, victimized

Need the answer right now

Judgment, blame

Personality diagnoses

“I just know I’m right!”


Watch for body language


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Watch for body language


Watch for “I feel that….…you have poor judgment.””””

(judgments)

…it’s your fault!””””(blame)

…you are attacking me!””””(attributions)

…you are passive-aggressive.””””(generalizations)

…the answer is…””””(cognitive)

Bundles of

feelings and

thoughts


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Name feelings - modulate your intensity

High intensity

Pissed off

Angry

Shocked

Low intensity

Concerned

Unsettled

Puzzled


Beyond flight or fight Learn triggers and clues for reactivity

Separate feelings and thoughts

Name feelings -modulate your

intensity

Acknowledge their feelings as

legitimate

Allow others to vent without reacting

Identify positive feelings

Focus on interests


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Feelings often heart of the matter

Unexpressed feelings:

• Corrosive

• Make it difficult or impossible to listen, understand

• Take toll on our self-esteem and relationships

Examine your emotional footprint:

• How is conflict handled in your family? Your culture?

• Explore the feelings under the anger, the judgments and

accusations

Professional cultures complex

• Have large impact on values and assumptions

of an organization

• Elicit cultural beliefs by uncovering conscious

assumptions that motivate behavior

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Personal Reflection - how did you

learn to manage conflict?

• Take 2 minutes to think about how your family

or origin, or your culture(s) including your

professional culture have influenced you

• Share with a partner, 4” each

• Then, share at your table

Large group debrief

Conflict Styles

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Thomas-

Kilmann

Conflict

Styles

A story

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https://www.youtube.com/watch?v=DEnlPQivbJo

Beware of assumptions

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Ladder of Inference

6. I take actions based on my beliefs

5. I adopt beliefs

4. I draw conclusions

3. I make assumptions

2. I add meaning

1. I select “data” - my observations

Example - Ladder of Inference• You and Jessie are working on a project – you need her help + data

• You email her – no response.

• You leave her a voice mail or two

• You remember last time you worked together ….

• She is avoiding you… As the days roll by, you convince yourself that

she is even trying to sabotage you.

• In fact, she never liked you.

• If she needs something from you, forget it - you won’t share it!

• You can’t stand her either and start to complain to others about her

• Next time you see Mary, you give her a dirty look and other team

members notice the communication breakdown

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Ladder of Inference

My View Mary’s View

Conclusion

I can’t stand her! I hope to catch up soon.

Reasoning

My colleague can’t stand me She knows that I’m overwhelmed.

Assumptions

When people don’t respond, they don’t like

you

When you don’t respond, people understand

that something must be going on.

Directly Observable Data

Jessie didn’t answer my email or my messages I’ve been so distracted since my Mom got

hospitalized – I can’t keep up at work

Climb Down the Ladder

Take a step back:

• What was the observable data?

• Do we agree on the data?

• What assumptions did I make?

• What conclusions did I draw?

• How did those conclusions influence my subsequent

observations?

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Ladder of Inference Exercise

• Choose an interpersonal situation that was difficult for you - perhaps the relationship you have with the other person is challenging or you regret something you said or did

• Choose a situation that felt important, that is likely to recur and that you are willing to learn from

Potential conflicts:• you can't reach agreement with your colleagues or with a patient

• someone is not pulling his or her weight on a team

• you believe you are being treated unfairly by your boss or supervisor

• you believe your point of view is being ignored

Ladder of Inference Exercise

• What assumptions did you make that contributed

to the conflict?

• Seek disconfirming data!

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Relationship affects conflict and vice versa

• Conflict in medical teams and in patient care often involve interpersonal incompatibilities

• Detracts from effective functioning

Greer et al, 2012; Kalishman et al, 2012

Relationship as a conflict transformation tool

PEARLS:

• Partnership

• Emotions

• Acknowledgement (or Apology)

• Respect

• Legitimization

• Support

Marvel et al, JAMA 1999; Langewitz et al, BMJ 2002

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PEARLS statements

Partnership: “I’d like to work with you, not against you.”

Empathy: “You seem pretty frustrated.”

Acknowledgement/apology: “What I’m hearing is that you are finding it difficult to interact well with the physicians on the team.”

Respect: “I see how much thought and work you have put into this.”

Legitimation: “Most people I know would also feel troubled after an event like that.”

Support: “What can I do in the next team meeting to support you?”

Convey empathy nonverbally

Use:

• Pause

• Touch

• Facial expression

• Tone of voice

• Space

Ambady et al, Surgery 2002

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Be aware of your own reactions

Requires self-awareness &

non-judgmental attitude

• How am I feeling?

• Separate the behavior

from the person

• Speak as an equal partner

• Focus on strengths

Attending to Relationship:

Skills Practice

Skills

1. Make at least one empathic statement

2. Convey empathy nonverbally

3. Be aware of your own reactions

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Reflective Listening

• Listen, express interest, and understand the

meaning of what the speaker is saying – with a

minimum of preconceived agenda

• Reflect the speaker’s words:

- repeat what you heard, including nonverbal

messages

- short summaries

• Non-verbally remain attentive, open, non-

judgmental

Reflective Listening Demo

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Skills Practice 6 minute exercise, then 6 minute debrief

• Work in pairs

• You will be in two different roles for 3 min each

1. Storyteller: Describe a challenge in a working relationship – with a patient, colleague, supervisor, etc.

2. Interviewer: Do NOT ask questions, share your stories, or problem-solve. Use only reflection and empathic statements.

“Mm hmm … Sounds like you were angry … That’s really tough …”

1.Stay Balanced: successful negotiators are calm, patient,

observant.

2.Be attuned to your counterpart: if they are feeling defensive

and hostile, everyone will be dragged down.

1.Influence your counterparts’ emotions

1.Resilient: self-awareness is key

Goal - emotional self-awareness, self

management

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Negotiating Differences

Ask

Respond

Tell

Summarize

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Negotiating Differences:

ARTS of Communication

• Ask the other’s perspective – use active listening

Distinguish interests from positions

• Respond with empathy and use reflective listening

• Tell your perspective and your interests– Beware of assumptions

• Summarize your understanding of the other’s perspective, their interests and focus on shared interests

• Seek solutions - generate options

Active Listening

• Chinese character for listening includes:

- an ear

- an eye

- a line for undivided attention and

- a heart

• Prepare yourself to listen

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Goals of Active

Listening

• Help a speaker feel heard, understood

• Encourage exploration at a deeper level

• Strengthen the relationship

• Understand different perspectives

• Show respect

Listen, don’t reload!

Dialogue, not discussion

Dialogue: “flow of meaning”

•Inquiry to surface ideas, perceptions, and new

understandings

vs discussion: “to break apart”

•People defend and hold onto their differences

•Often devolves into rigid debate, see others as

“positions” to agree with or refute

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And listen to yourself

• Understand your anger and other feelings beforeengaging in a difficult conversation

• Negotiate with your feelings • What assumptions am I making?

• What story am I telling myself about their intentions?

• Describe your feelings carefully, and gently

• Use “I” statements - “You …” statements often heard as blaming

“I feel angry” vs “ You make me so angry”

Perspective

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Ask about interests, underlying

positionsPositions

• What we want, need, think,

or feel

• Drawing a line in the sand

• Basis for debate

“I can’t let Bobby transition to

the adult team”

“ Why 4 mandatory visits per

year?”

Interests

• The motivations for our

positions: our needs,

desires, concerns, fears,

aspirations

• Basis for dialogue

“I’m afraid the adult team won’t

understand how to work with

Bobby.”

“I worry they won’t provide the same

level of flexibility and care.”

Interests

Positions

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Different kinds of interests

Interests

Process

Identify Shared Interests

• Uncover and highlight shared interests

• Remember that you and colleagues

are allies and have many shared goals

• Incompatible interests do exist…

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• Respond with empathy, reflective listening

• Tell your perspective and your interests

• Summarize your understanding of the other’s perspective, their interests and focus on shared interests


What you

mean to say

What is understood

What you say

What is heard

Reflective Response

Potential Pitfalls in Communication

Adapted from Health Behavior Change by Stephen Rollnick

“The single biggest problem in communication is the illusion that it

has taken place.” George Bernard Shaw

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Reflection reduces resistance

Goal: confirm your understanding, deepen relationship

Qualities of a good reflection

- clear, concise

- accurately identifies the meaning underlying your

colleague’s words

-followed by a pause

Multiple ways to reflect

• Repeating or rephrasing – mirror the speaker’s

words

• Paraphrasing – infer meaning from what speaker

said

• Reflect feeling underlying the words –emphasize

emotional aspects of communication

Reflection demo

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• Respond with empathy and reflective listening

• Tell your perspective and your interests

• Summarize your understanding of the other’s perspective, their interests


Prepare for conflict

• Be clear about your goals for:

- the relationship

- the substance of conflict

• Distinguish interests vs. positions

• Distinguish feelings from thoughts

• Check your assumptions

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ExercisePreparation for conflict; interests vs. positions

• Case scenario

You have recently been promoted from nurse manager of a primary

care clinic to be the Chief Nursing Officer for a large integrated health

system with 20 primary care clinics and more than 15 specialty clinics.

There is a huge backlog of patients from primary care waiting for

appointments in many specialty clinics. You have been appointed by

the CEO to chair a steering committee to guide an improvement effort.

The CEO has said there is NO additional money for solutions.

• For this meeting:

• Make sure we understood each other.

• Agree to meet again.

• Longer term:

• Maintain a strong working relationship so we can continue to work

together to solve problems.

• For this meeting:

• Discover any common ground.

• Longer term:

• Assure patient access.

• Assure physician involvement in scheduling.

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I feel disrespected and that my

opinion doesn’t matter

I feel this person will be a problem

to work with; I feel he’s a bully

I feel he’s a small-minded jerk

I feel that this guy’s going to be hard

to work with

I feel misunderstood, and working

toward something different than I

was

Angry

Afraid/scared

Sad

Hurt

Fear

Frustration

Concerned

• I feel that the surgeon is a

mean-spirited, arrogant jerk.

• I feel enraged that one person

can be so controlling and

aggressive.

• I feel frustrated.

• I feel timid.

• I feel stuck.

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We have to have a 1-1 conversation

We must find some shared interest

Centralized scheduling

Exemplary patient access

Strong systems – people and process

Seen by peers as an effective leader

Having a good working relationship;

Understanding underlying resistance

Patient satisfaction

• Dispersed scheduling

• You don’t know what the

demand for patient safety is

• I want to see the patient

when I need to – you don’t

have experience with what

I am doing

• I have complex

consultations

• Schedule to run smoothly

Patient access

Autonomy

Control, comfort

Exemplary patient care

Maintaining credibility with peers

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• Take control over physician

schedules

• Get the problem solved right now

• Offer best care and services to

patients

• Offer appointments when needed

• Strong ongoing collaboration with

physicians

• Maintain good relationship with

CEO

• More specialists are needed

• Clinicians must have absolute

control over schedules

• There should be no productivity

rules

• Offer the best possible patient

care

• Scheduling meets needs of MDs

• Having a collaborative

relationship with other team

members is important

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Demo

• CNO Role

– Has done the preparation and takes the lead with

ARTS

– Goal to find mutual interests

• MD Role

– Not prepared

– Does not know what to expect in the conversation

Additional slides for your reference

• The following three slides complete the

preparation document for the case scenario.

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• I feel that the administration has

terrible judgment.

• I feel that the CNO is incompetent.

• I feel concerned.

• I feel disappointed.

• I feel frustrated.

• The surgeon is trying to

undermine me.

• Specialists always want to get

their way.

• The surgeon won’t ever collaborate!

His words:

• Patient care is not a priority for

administrators.

• Clinicians do not have enough

resources.

His behavior:

• He attends meetings regularly.

• He allows others to talk without

interrupting.

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• Administration’s top priority is always money.

• The CNO does not understand

specialists’ needs.

• The CNO always wants to tell MDs

what to do!

Her words:

• Administration began this initiative

because patients could not get

access to care.

Her behavior:

• The CNO asks questions to find out

about specialty services.

• The CNO has invited the specialists

to be on this committee.

Practice a conflict scenario in pairs10”

• Identify a current conflict in which you are faced

with a person entrenched in a position

• Describe the situation briefly to your partner

• Your goal is to identify their interests and find

shared interests

• Group debrief

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15 minute Break

ARTful Skills in Delivering

Effective Feedback

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The art of facilitation and feedback

Feedback: originally, a directional system that provides information to a rocket about its course and cause it to correct

• Stay in this direction

• Go more…

• Go less...

Why feedback?

• Mastery of skill

requires

– Deliberate practice

– Feedback

Ericsson et al, 2007

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About feedback

"Courage is what it takes to

stand up and speak.

Courage is also what it takes

to sit down and listen”

Winston Churchill

Feedback is an expression

of commitment to the relationship

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What is the optimal ratio of

reinforcing to corrective feedback?

Rudy et al, Eval Health Prof 2001

:

Features of effective feedback

• Tying feedback to goals

• Understanding the other’s goals can help

• Calibrating the amount of feedback

Hewson and Little, JGIM 1998

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Giving Feedback: Steps

• Set up

• Gather Information / Observe

• ARTful Feedback

Reinforcing

Constructive

Next Steps

Bienstock et al, Am J Ob Gyn 2007

Set-up

• Creating a permissive environment for

maximal collaboration

- In context of collegial relationship

- In the spirit of dialogue rather than downloading

• Features:

- Temporally close to event

- In accordance with shared team goals

- In accordance with other’s readiness

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Gather information

• Transcribe what is

happening

- Verbal

- Nonverbal

• Record words and/or

behaviors to give

feedback about

- Avoid “You were…”

- Practice “I saw…”; “I

heard…”; “I noticed…”

A challenging interaction

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The ART of communication• Ask open-ended

questions

• Respond with a

summary or empathic

statement

• Tell your perspective

• Continue the cycle if

necessary

ARTful Skills

• Ask– Self-assessment

– Recall previously-stated goals from Set-Up

• Respond– Depends on active listening

– Using empathic words can be helpful

• Tell– Your own assessment and thoughts

– Behavioral and specific

– Can illuminate blind spots

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ARTful Reinforcing Feedback

• Ask: What do you think you’d like to continue

doing?

• Respond, Tell

• The ART cycle continues: ask for reactions to

your feedback

Example: Reinforcing Tell

Situation: “In the meeting, when you were eliciting Jane’s

perspective, ”

Behavior: “I saw that you allowed her to interrupt you with

her expression of frustration, and you leaned forward and nodded.”

Impact: “I really appreciate the non-verbal expression of

partnership.”

McCauley & Velsor, 2004

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ARTful Constructive Feedback• Ask: What would you change / do differently?

• Respond, Tell (remain nonjudgmental)

• Continue the ART cycle: ask for reactions to your feedback

In challenging situations:

• Ask about intention

• Respond with empathy or a summary

• Tell your perception of how intention and impact differ

PEARLS

- Partnership: “I’ll work with you on this problem”

- Empathy: “Sounds like it was frustrating not to get the

result you wanted”

- Acknowledgement/Apology: “That was a difficult

situation to be in”

- Respect: “I can see how much you tried to connect”

- Legitimation: “Most people find similar situations

challenging”

- Support: “I want to help you achieve your goal”

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Example: Constructive Tell

Situation: “When you responded to Lance’s resistant comment,”

Behavior: “I noticed that you raised your voice and interrupted

him.”

[Consider an “ask – respond” loop here: “What was going on for you at the time?”]

Impact: “I think that’s when he started raising his voice back to

you.”


ARTful Next Steps

(Seek solutions)• Ask, respond, tell

• Agree on action plan and accountability

– When we will follow-up to check-in?

– What are our expectations for our next meeting?

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Example: Next Steps Tell

Situation: “When you responded to Lance’s resistant

comment,”

Behavior: “I noticed that you explained your intention.”

[Consider an “ask – respond” loop here: “What alternative responses might you have had?”]

Impact: “I wonder if he might have relented a bit if you had

asked him what his intention was first, before sharing your own?”


Giving Feedback: Summary

• Set up: check reactivity, modulate emotions

• Observe specific, concrete behaviors

• Ask permission

• Respond with empathy

• Tell using “I” statements, your own perceptions

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Summary

� Set up

� Gather Information / Observe

� ARTful Feedback

Keep (Reinforcing)

Stop (Corrective)

Start (Next Steps)

Receiving Feedback

• Check emotional reactivity

• Reframe with systems view / opportunity to learn and improve

• Intersection between us

• Roles we play

• System influences


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Receiving Feedback

• Feedback as a gift

• Hold back on disagreement / your own viewpoint

• Check understanding with active listening

• Respond using active telling


The conversation in my head … I might …

TRUTH triggers “That is wrong.”

“You don’t know what you’re talking

about!”

Reframe: “Tell me more”

Look for your blind spots

RELATIONSHIP

triggers

“After all I’ve done for you!”

“You’re the problem, not me!”

Separate person from

content

What are we each

contributing?

IDENTITY triggers “I screw up everything”

“I’m hopeless”

“I’m not a bad person – or am I?”

Reflect on why I react,

based on my life story

Dismantle distortions

Right size the feedback

Change into learning

opportunity

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ReferencesBooks:

1. Getting to Yes by Roger Fisher, William Ury and Bruce Patton 3rd edition 2011 Penguin Books

2. Difficult Conversations, How to Discuss What Matters Most by Douglas Stone, Bruce Patton and

Sheila Heen. 2010 Penguin Books

3. Thanks for the Feedback by Douglas Stone and Sheila Heen. 2013 Penguin Books

4. Nonviolent Communication by Marshall Rosenberg, 2008

5. Dialogue: The Art of Thinking Together by William Isaacs, 1999

Articles:

Aschenbrener, CA et al. Managing Low to Mid Intensity Conflict in the Health Care Setting The

Physician Executive, July/Aug 1999; pp 44-50.

Greer, LL et al. Conflict in medical teams: opportunity or danger? Medical Education 2012: 46: 935–

942

Janss, R. et al. What is happening under the surface? Power, conflict and the performance of medical

teams. Medical Education 2012: 46: 838–849

Rosenstein, AH. A Survey of the Impact of Disruptive Behaviors and Communication Defects on

Patient Safety, JCAHO, 8-08

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