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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
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Blame and Shame
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Identify Culture
• Communication
• Behavior
• Rituals
• Tolerance
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OR Safety Attitudes Questionnaire - SAQ
12. In the OR, it is difficult to discuss errors. 1 2 3 4 5
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SAQ Participants
N=165
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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
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Launch of Team Training
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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
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Why Team Training?
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Next Steps
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Presentation Objectives
• Describe the root of conflict
• Understand how to reframe during negotiations
• Learn the Walk in the Woods Technique
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Conflict in Health Care
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Recipe for Conflict
?Ambiguity
Complexity
Vagueness
Competition
Hierarchy
High stress
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Recipe for Conflict
CONSEQUENCES
Mistrust Disruptive Behavior
Changes in Policy
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Is All Conflict Bad?
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Power and Negotiation
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Positional Bargaining
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Interest-Based Negotiation
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Positional Bargaining
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Walk in the Woods
A Path to Interest-Based Negotiation
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Geneva, Switzerland 1982
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Step by Step Approach
Problem
Self-Interests
Enlarged Interests
Enlightened Interests
Aligned Interests
Solution
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Stakeholders
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Self-Interests (Phase 1)Problem
What Gains can come from this meeting?
Building Confidence(Trust)
Active Listening
Constructive and safe zone expression of interests
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Self-Interests
Productive Conversation Recognition of the complexity of the Problem
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Enlarged Interests (Phase 2)
Agreements Disagreements1) Hire new staff 1) Reduce benefits 2) Measure quality
2)
REFRAMING
Self
Enlarged
Shared Mental Model
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Enlarged Interests
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Enlarged Interests
How can we REFRAME to avoid this scenario?
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Enlarged Interests
What is it we agree upon?Identify and interpret each choice
Encourage questions to generate discussion
REFRAMING
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Learning StepsSelf Interests Enlarged Interests
Investment
Physical
Emotional
Spiritual
Financial
Unlearning
New Learning
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Enlightened Interests (Phase 3)
Imagine if….?
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Enlightened Interests
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Enlightened Interests
No Commitment Zone
Encourage open thinking and discussion
HumorCreativityExploration of ideas
Spurring momentum
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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
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Enlightened Interests
The Capacity to Imagine
Deal Makers Deal Breakers
IDEAS IDEAS
Further Negotiation3 1
2
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Aligned Interests (Phase 4)
Redefining Success
I We
Overlapping Interests
Mesh
Alignment
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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
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Aligned Interests
Fair Equitable
Meets the Test of Time
Collaborative
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Aligned Interests
Record and Sign the Agreement
Celebrate the Agreement
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Action Steps
Enlightened Interests Aligned Interests
Negotiation from a Uni-dimensional approach
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Action Steps
To a multi-dimensional approach
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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
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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