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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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Relational Substantive
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!”
Created by Neil Baker M.D. for AACH
Watch for body language
Created by Neil Baker M.D. for AACH
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Watch for body language
Created by Neil Baker M.D. for AACH
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
Created by Neil Baker M.D. for AACH
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Name feelings - modulate your intensity
High intensity
Pissed off
Angry
Shocked
Low intensity
Concerned
Unsettled
Puzzled
Created by Neil Baker M.D. for AACH
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
Created by Neil Baker M.D. for AACH
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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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Relational Substantive
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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Negotiating Differences:
ARTS of Communication
• Ask the other’s perspective – use active listening
• 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
• Seek solutions - generate options
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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Negotiating Differences:
ARTS of Communication
• Ask the other’s perspective – use active listening
• Respond with empathy and reflective listening
• Tell your perspective and your interests
• Summarize your understanding of the other’s perspective, their interests
• Seek solutions - generate options
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.”
McCauley & Velsor, 2004
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?”
McCauley & Velsor, 2004
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
Greer et al, 2012; Kalishman et al, 2012
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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
Greer et al, 2012; Kalishman et al, 2012
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