Conflict Management in Health Care

The Tipping Point Arrives

Phyllis Beck Kritek

“There is no power for change greater than a community discovering what it cares about.”

—Margaret Wheatley

All human endeavors eventually find the participants differing, becoming oppositional about incompatible needs, drives, wishes, or demands. Conflict is intrinsic to human interaction, and health care environments are not exempt. This propensity to differ with an antagonistic response is familiar, dynamic, emergent, often surprising, and always contextual. The overriding context in the United States is germane: The emergence of conflict is often experienced as a threat.

In part, this can be traced to the central metaphor of our culture—one of competition, argument, and indeed war (Lakoff & Johnson, 1980). Within this metaphor is the unstated assumption that the person with the power “wins.” The primary meaning of power—self-agency—has been culturally supplanted by the secondary meaning of power—dominance over another (Kritek, 2002). So, difference and disagreement can trigger a predictable sequence of threat, strife, discord, and defeat. We are habituated to conflict as adversarial, evoking both fear and defensiveness, often reactive.

Management also has a variety of meanings; it can mean both “directing with skill” and “keeping others compliant.” Confronted with interpersonal volatility, we often try to do both, while concurrently managing our own responses. Managing conflict is always a challenge.

Managing Conflict through Alternative Dispute Resolution

It is within this context that the field of conflict resolution, usually referred to as Alternative Dispute Resolution (ADR), emerged in the U.S. ADR refers to a rich array of processes used by individuals and groups to resolve disputes, make decisions, or improve relationship outcomes. It is rooted in international diplomacy practices, the historic relationships between employers and employees (particularly through the union movement), and a variety of social technologies emergent from social sciences. ADR as a distinct practice and discipline began to flourish in the 1990s. In the first decade of the 21st century, it became “normalized” in government structures and corporations, often viewed not so much as an attractive alternative but more as a cost-saving option. It was cheaper than litigation. ADR educational programs multiplied and flourished. The U.S. health care delivery system, though, was unique in its resistance to this ADR expansion. That has changed.

I have worked for almost 25 years to build a bridge between my colleagues in health care and my colleagues in the burgeoning field of ADR. My motivation stemmed from experiential and anecdotal data: The conflict aversive and avoidant behaviors of health care professionals put patients at risk. Databased evidence was slowly building (e.g., Shortell et al., 1994), substantiating my concern. Our failure to manage conflict effectively was a threat to patient safety.

In the previous edition of this book, I briefly traced the history of ADR in the U.S., mapping the policies, executive orders, and legislative initiatives that have embedded ADR in governmental structures (Kritek, 2005). I also discussed the most high-profile approach to conflict resolution, the use of principled negotiation as the tool of choice. Principled negotiation is an interest-based approach that focuses primarily on conflict resolution. It is considered an “integrative” approach, one in which negotiations aim to create outcomes that meet all parties’ essential needs and maximize benefits for everyone (Mayer, 2000, p. 151). The concept of principled negotiation was introduced in the landmark, now classic book, Getting to Yes by Fisher and Ury (1981; 1994). They also introduced the concept of “win-win” negotiations, drawing on game theory, the theoretical roots of much of the early conflict resolution research. These two authors and their colleagues were responsible for much of my early training in ADR, and hence this focus on “interest-based” negotiation shaped my worldview as it has many, if not most ADR practitioners. Newer models are now emerging.

ADR has increasingly been adopted as an essential resource in a variety of conflict arenas including labor and industrial disputes but also consumer, community, family, environmental, organizational, federal and state governmental, and international disputes. The primary focus of these initiatives was to create mediation options for disputants. These options could reduce obstacles to communication, explore alternatives, transcend adversarial behaviors, and address the needs of all parties. The assistance of a “third party,” who was described as “neutral”—a mediator—helped participants through this process (Folberg & Taylor, 1984).

Health Care: The Last Frontier in ADR

As ADR intensified its impact on all aspects of the U.S. culture, the health care community was generally disengaged and reactive. We gave lip service to the importance of collaboration while concurrently avoiding or suppressing conflict. Robson and Morrison (2003) posited that health care was the last big ADR frontier. They listed four health care characteristics that explain why it may be less likely to use ADR approaches in solving its problems. Specifically, health care:

1. is a complex adaptive system, which makes it harder to understand;

2. has widespread inequalities and imbalances of power, knowledge, and control;

3. has widely divergent “cultures” and value systems among the various professional and nonprofessional groups working within the system; and

4. struggles with the difficulty inherent in identifying the parties who should sit at the table.

There were additional germane forces in play. Reliance on litigation as a problem-solving device is a difficult behavior to overcome. Conflict avoidance was a normalized cultural norm. Leadership practices grounded in the exercise of power over others were equally normalized, though often denied. Health professionals did not welcome ADR professionals as helpful or valued consultants but as potential threats, requiring unwelcome behavior changes, manifesting a propensity for “naming elephants in the room” (Hammond & Mayfield, 2004).

In lieu of investing in ADR, the health care community invested in other related or contrasting services and programs. Ombudspersons addressed some of the concerns of patients and their families about care or experiences that they viewed as troublesome. The human resources division of many health care systems and hospitals integrated some cursory brief training on conflict management into their educational programs. Ethics committees attempted to address the moral dilemmas that confront health care providers today and provided reasoned reflection on options and opportunities. And, finally, the legal representatives of health care communities often viewed disputes as their terrain, where the use of the justice system was accessed embracing traditional approaches and models. All of these factors shed some light on the reluctance of health care communities to become active participants in ADR.

The Tipping Point Arrives

The past is always prologue. “The Tipping Point” refers to the moment when an idea, trend, or social pattern meets a threshold that leads to rapid change. It was popularized as a concept through Malcolm Gladwell’s book of the same name where he posited that “Ideas and products and messages and behaviors spread just like viruses do” (Gladwell, 2000, p 7). Gladwell suggests that three principles create the conditions for a tipping point to occur: contagiousness, the fact that little causes can have big effects, and that change happens not gradually but at one dramatic moment (p. 9). The U.S. health care community, historically resistive to ADR policies and practices, has reached this threshold of change. Health care communities are now actively exploring the possibilities presented by ADR practices due to the convergence of a cornucopia of forces and factors. Some of the most salient forces are described in the following paragraphs and provide context.

The Institute of Medicine Focuses on Safety, Creates a Movement

The Institute of Medicine (IOM), established in 1970, is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public. In 1999, at the conclusion of a fractious decade in health care awash with downsizing, re-engineering, and hostile takeovers called mergers, the IOM captured the attention of the nation by publishing a report, “To Err is Human: Building a Safer Health Care System” (Institute of Medicine, 1999). This report documented the magnitude and severity of preventable medical errors, which they called “adverse events,” and called for a shift from a blame response to one of finding causes and fixing problems. They provided an array of proactive recommendations to that end. And they catalyzed the patient safety movement.

Two subsequent reports by the IOM added to the impact of this report. “Crossing the Quality Chasm: A New Health System for the 21st Century” (2001) called for an overhaul of the U.S. health care system and further energized the focus on health care quality and safety. “Keeping Patients Safe: Transforming the Work Environment of Nurses” (2004) amplified the focus on patient safety by identifying the problems in health care environments that threaten patient safety and impact nursing care. The push for improved patient safety created a tipping point.

The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorized the creation of Patient Safety Organizations (PSOs) to improve quality and safety by reducing the incidence of events that adversely affect patients. The Patient Safety Act authorized the Agency for Healthcare Research and Quality (AHRQ) to facilitate the development of a network of patient safety databases (NPSD) to which PSOs, health care providers, and others could voluntarily contribute nonidentifiable patient safety work products. The Patient Safety Act directs AHRQ to incorporate the nonidentifiable trend data from NPSD in its annual National Health Care Quality Report (NHQR), available at www.ahrq.gov/qual/qrdr07.htm.

These data swiftly revealed that one of the most consistent findings in emergent research focused on the inability of health care providers, individually and collectively, to collaborate and constructively engage in conflict. This inability became an underlying theme in these and related studies that could no longer be denied or ignored. Abruptly, the need to craft a new relationship model became apparent. After decades of purportedly supporting collaboration, health care professionals were confronted with a new meaning to their central ethos: “Do No Harm.” Authentic collaboration and constructive relationships were not optional; they had become a moral imperative. The refusal to take action could now be viewed as a form of negligence and harm. A tentative bridge between health care and ADR communities began to emerge.

The Joint Commission

The Joint Commission (TJC), previously called The Joint Commission for the Accreditation of Health Care Organizations, is an independent, not-for-profit accrediting body founded in 1951. TJC conducts on-site evaluations of over 17,000 health care organizations in the U.S. every 3 years to ensure that they provide “safe and effective care of the highest quality and value” (TJC Mission Statement, 2010).

Accreditation surveys are organized through established standards that health care organizations must demonstrate they have met; TJC standards thus carry disproportionate impact on health care organizations’ policies and practices. Risking accreditation is risking a viable future.

TJC introduced new standards, effective January 2009, which focused on two new areas of concern: disruptive behavior on the part of health care professionals and the need for conflict resolution competencies as a component of health care leadership. Box 12-1 provides the actual language of the new standards and/or performance measures now embedded in the accreditation process. These changes accelerated the engagement of the health care community in the possibilities of ADR in health care.

BOX 12-1

Joint Commission Leadership Standards—Effective January 2009 (Components Referring to Conflict Management and Disruptive Behavior)

Leadership Standard (LD 2.40)

Standard: “The organization manages conflict between leadership groups to protect the quality and safety of care.”

Elements of Performance