Haavi Morreim: The results of conflict can be adverse outcomes
Last year I had the unique opportunity to participate in Conflict resolution in healthcare settings, mediation in healthcare workshop, provided by Haavi Morreim, JD, PhD, Principal in the Center for Conflict Resolution in Healthcare, LLC (www.healthcare-mediation.net), which provides consulting and training for conflict resolution throughout healthcare. She is also the Chair of the Healthcare Committee; American Bar Association (ABA), Dispute Resolution Section and the Chair of Task Force on ADR and Conflict Management; ABA, Health Law Section.
I have decided to tell you more about the importance of ADR and their implication in healthcare settings. Those methods not only assist for easier, painless, cheaper and satisfactory resolution of conflicts, but have a very important role in the adverse events prevention. The explanation is simple: conflicts lead to poor communication and fragmented healthcare, and therefore create system, prone to errors.
What are the implications of conflict management in healthcare settings and specifically mediation in healthcare?
I would like to begin by distinguishing several types of conflict resolution. At one end of the spectrum is coaching: a person in conflict may ask for a sounding-board to help him or her “think out loud” about how best to manage the situation. The coach can offer ideas that the person would then be free to adopt, or not. On a somewhat more involved level, a conflict intermediary can offer informal negotiation services among people in conflict, a kind of “shuttle diplomacy” or facilitation whose goal is not to tell people what to do, but rather to help them explore their options and decide for themselves what they wish to do. Beyond this, mediation is a somewhat more formal process in which someone who is neutral in the conflict brings the same basic “toolbox” of skills and strategies used in other forms of conflict resolution, to help people in conflict identify and resolve the issues they face.
In healthcare, conflicts – here, simply defined as significant differences of perspective regarding goals, or the best ways to reach those goals – are common. Physicians, administrators, nurses, and allied providers previously accustomed to great independence are now intensely interdependent among each other; collectively they strive to meet the needs and expectations of patients and families whose goals and reasons may not always be clear. Similarly, providers’ perspectives do not always mesh with administrators’. The results of conflict can be adverse outcomes, staff and physician burnout and turnover, department-level dysfunction, medical malpractice suits, and patient/family dissatisfaction, among other problems.
Can you tell us more about hospital ombudsman and how are they relevant to patient safety?
As described just below, there are several kinds of ombuds. The type generally found in medical centers is the “organizational ombuds,” and many medical centers have them. Typically these ombuds focus on the issues arising for employees and staff – ranging from physicians and nurses, to security personnel, maintenance and housekeeping staff – as distinct from patient-provider issues.
A properly structured ombuds office features several characteristics. First, the ombuds is independent, reporting only to top management. This way, the ombuds does not risk job loss, e.g., for honoring the next principle: confidentiality. Those who visit the ombuds office will not be willing to share personal information or raise awkward questions, nor thereby be able to address difficult conflicts adequately, without assurance that their communications will be private. A third principle of ombuds is impartiality: the ombuds does not take sides between the parties, nor direct parties as to which option(s) the ombuds thinks they should adopt. This, in turn, raises a fourth principle: voluntariness. People in conflict are unlikely to seek assistance, or come to a durable resolution, if the outcome of their negotiations is not genuinely the product of mutual agreement. “Agreements” reached through bullied acquiescence rarely stand the test of time.
Another, very important function of ombuds is to report back to senior leadership regarding system-level issues within the organization. Without compromising confidentiality, the ombuds might be able to show, for instance, that in this particular medical center there are many employees who feel their supervisors do not listen to their concerns, or that they are not treated with respect, or that various organizational decisions and processes are not made sufficiently clear to employees. These are the system-level issues that a well-functioning organization will want to know about, for its continual quality improvement efforts.
What other types of ombuds are there?
Several quite distinct types of ombuds (or “ombudsmen” or “ombudspersons”) can be found. Historically, the first kind to emerge was the “Classical Ombuds.” Often though not always found in the context of government activities, classical ombuds are authorized to independently and impartially investigate complaints. This rather formal responsibility includes a fact-finding function and can even include subpoena power.
An “Executive Ombuds” can be situated in either the public or private sector, and has the primary task of receiving complaints, whether from the public or through internal channels. Although they usually do not have formal investigative authority, they can provide feedback to the larger organization.
“Advocate Ombuds” are created to serve as advocates for specific groups such as residents of nursing homes or prisons. Here, the neutrality ombuds usually embracew may be limited, as the ombuds determines whether and to what extent the identified constituency needs to be defended via affirmative help and advocacy.
Finally, the “Organizational Ombuds” discussed above can particularly be found in colleges and universities, and in private companies. Here, the focus is on [1] providing conflict resolution assistance for persons and groups who seek help in resolving their differences, and on [2] providing feedback to the broader organization regarding ways in which to improve its overall function, the ways it treats its own members, and how it serves its broader constituencies. This last type, as noted, is the kind found in many healthcare organizations, in the recognition that conflict in healthcare is not only stressful and demoralizing for those most directly involved, but can also be a crucial factor in the healthcare system’s ability to provide high-quality, safe, and efficient care.
Do conflict resolution and mediation in healthcare help to build a culture of safety and shift from the blame-oriented culture?
Broadly available, user-friendly opportunities for resolving conflict can surely help to move a healthcare organization from a blame-oriented to a safety-focused, problem-solving culture. Indeed, a key tenet of mediation is “focus on the problem, not the people.” Several years ago, for instance, a local hospital realised that orders for “stat” antibiotics often took several hours to be filled, rather than the recommended half-hour. It would be tempting to blame the phamacists for being slow, inefficient, or lazy. But “focus on the problem” revealed that (at that time) “stat” orders were sent to a fax machine located at the back of the busy pharmacy. If no one happened to hear the fax macine go “ding!” then the order might not be discovered promptly. A further “focus on the problem” step revealed that moving the fax machine closer to the pharmacists would not necessarily help, because it would take up valuable counter space needed for preparing and filling orders.
Almost always, respectful listening and problem-solving (which lie at the heart of conflict resolution) reveals that a difficult situation is actually very different from what people initially believed or presumed it to be. Still, in the heat of conflict, listening can be difficult to do; hence, someone skilled in helping to parties to redirect their focus and re-focus their thinking can be enormously helpful, system- and culture-wide.