Tuning the System: Program Buffers Care Collisions
Authored by Carol Morton
Reprinted with Permission from Focus News
From Harvard Medical, Dental and School of Public Health
January 11, 2002

Everyone in health care, it seems, has a war story about conflict at work.

Researchers tussle over whose name goes on a publication and in what order. Frustrated patients and worried relatives question doctors' decisions and complain to the medical board. Physicians second-guess nursing staff. Department heads battle for control after hospitals and health care systems combine. And many folks know the endless struggle for more office, laboratory, and clinic space.

Conflict is a part of life and a part of work, but people can limit the time it consumes, the resources it wastes, and the disruption it causes. Changing the way disagreements are handled can yield outcomes that better meet the combined interests of those who have a stake in the negotiation. That is the message of Leonard Marcus, who directs the program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health.

A Four-step Approach to Problem-solving Four negotiation steps developed by the Program for Health Care Negotiation and Conflict Resolution guide minor and major negotiations in health care. The structured multidimensional problem-solving process is called "Walk in the Woods," after a famous story in which international negotiators at loggerheads over a nuclear arms treaty went for a walk in the woods near Geneva and discovered common interests that led to new solutions. Step one: self interests. Each participant articulates his or her view of key problems, issues, and options. They are encouraged to actively listen, question, and interact with one another. Step two: enlarged interests. The participants reframe their understanding of current problems and possible options with a wider perspective, based on the integrative listening and confidence-building that occurred in step one. Step three: enlightened interests. The group is ready to engage in innovative thinking and problem-solving, generating ideas and perspectives that had not previously been considered. Step four: aligned interests. Participants build common ground perspectives, priorities, action items, agreement, or plans for moving forward. Depending on the scope of the intended objectives, at this point they recognize the tangible contributions and opportunities accomplished through the meeting.

Boiling Over
"In health care, we are passionate about what we do, and that's a plus," Marcus said. "When passions collide, that same drive can be a source of conflict. The stakes are high--life and death, large amounts of money, big institutions, reputations. Therefore, people fight hard which, ironically, becomes an obstacle in and of itself."

Marcus uses a one-minute exercise to illustrate his point. About halfway through the program's flagship intensive one-week leadership training course held each spring, he calls for a time-out in the presentation about peacemaking.

"We've been doing a lot of talking," he says. "Let's get some physical exercise." Marcus tells people to assume the arm-wrestling position with the person sitting next to them. "Your job is to get the back of the hand of the other person down as many times as possible," he says. "Count how many times you get it down in the next 30 seconds." He waits five seconds, then says "go."

Typically, about two thirds of the class struggle to slam down their partner's hand and to resist their partner's attempts to do the same. Such a pair expends a lot of energy to defeat their partner and scores only one or two points between them. About one third of the partners offer no resistance to each other, but swing their arms easily back and forth. Such a pair can accumulate about 50 points working together.

Knowing the Terrain
The Boston area has an unusual concentration of courses, programs, and organizations dedicated to conflict resolution in domestic and international disputes. Yet it takes a peer to negotiate and resolve conflicts. A former U.S. president can work on peace accords among leaders of different countries, Marcus said, but he would likely flounder in the health care environment because of the unique organization, specialized vocabulary, and complex relationships found there.

So Marcus and his colleagues adapted for health care the basic principles of conflict resolution described in the popular business book Getting to Yes by Roger Fisher, William Ury, and Bruce Patton of the Harvard Negotiation Project. An annual one-week immersion course teaches skills to health care leaders from different organizations. The program also offers a day-long problem-solving clinic for senior and midlevel leaders from a single organization and facilitates meetings among organizations in the Public Health Conversations Initiative. In addition, program faculty teach focused seminars within continuing education courses for chiefs of clinical services, physicians in community health centers, health and human rights workers, and health care executives (see www.hsph.harvard.edu/ccpe).

"A lot of the methods are common sense," said Laurie Cowan, who attended the intensive week-long course. As vice president for capital planning and management at Children's Hospital, she has the unenviable task of assigning office, laboratory, and clinic space. "It's being a good listener. Putting yourself in someone else's shoes. Understanding where the other party is coming from. Helping others see the bigger picture. Leading people to a common understanding. There is no magic bullet."

Cowan applies these techniques daily. Over the past several months, she had to find new workspace for people who were occupying a building demolished three weeks ago as part of the clinical expansion project on Shattuck Street. "There was hardly any available space," she said. "We had to work with some people who had occupied their space for a long time. Others had been moved many times and were justifiably unenthusiastic about moving again. We had limited choices about where to go. If 500 square feet becomes available anywhere, we can sell it 10 times over. It's not a matter of compromising. It takes some hard work in situations to have everyone feel that they've been heard, that there has been some creativity brought to address the challenge, and that we've come up with a solution everyone can live with, even if not everyone is happy."

Outside Help
Daily problems unresolved by individuals and systemic changes driven by financial pressures sometimes require outside mediators. Orthopedic surgeon Barry Dorn took the first class Marcus offered 11 years ago and embraced mediation as a second career. In addition to his medical practice, he is associate program director and also works in a private mediation consulting business, Health Care Negotiation Associates.

"Conflict takes on a life of its own," Dorn said. "People in health care are absolutely dependent on each other. Continuous conflict among individuals or departments can have a shadow effect that spills over into the rest of the institution. We usually get called in when conflict has been festering awhile." Dorn recalls two merging hospitals in the Midwest. Differences ranged from the philosophical--research publications vs. patient quantity and quality of care--to the length of white coats worn by doctors, residents, and students. "The two systems did come together in the end and were able to realize tremendous savings," Dorn said.

Ultimately, conflict can interfere with the quality of patient care, said HSPH instructor Joan Roover, who also took Marcus's first class and two years ago joined the mediation practice with Dorn. "We're aware of organizations that are not able to reach consistent agreement among nurses and surgical staff on a simple policy like marking the surgical site," she said. "There's no excuse for that."

"There are not many organizations short of the aviation industry where life and death are on the line so consistently," Roover said. "We believe the health care delivery system can function more effectively if we take out conflict and replace it with more collaborative models."

Carol Cruzan Morton