Building trust and collaboration between physicians and administrators. (Leadership).

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EVERYONE SEEMED TO agree about only one thing -- there was no basis for physician-administrative trust at the hospital.

The physicians were certain that the administration was not committed to their patients. They believed administrators were solely focused on the bottom line and simply there to build their resumes before moving on.

Physician pressure resulted in the removal of the previous CEO and it looked to the medical staff as if they would' have to do it again. Major initiatives were being implemented without physician input. Physician recommendations essential to improving quality of care were being ignored.

To senior administrators, the situation looked quite different.

They had a clear vision. The problem was that physicians refused to buy in and support it. The physicians only seemed interested in their own personal well-being and pocketbooks.

The physicians complained a lot, were inflexible, too financially oriented and continually made derogatory remarks about the administration, refusing to look at their own failings.

As outsiders listening both sides, we wondered if the people involved could possibly be describing the same hospital. One thing was clear: Collaboration was dead and there was little agreement about what killed it.

How is it that these people working together could see such different realities? What can be done to pull these groups together?

Einstein told us that what we believe shapes what we see. Consistent with this view, psychological research demonstrates that beliefs and interests influence perceptions.

When we're hungry, those TV food ads command our attention. When our political or religious beliefs are challenged, it is difficult for many of us not to notice and respond.

Physician/administrator differences

Where do our inner reactions come from and why are they often so different for physicians and administrators?

Early in life, people who later end up in these roles already see different realities and respond to different possibilities. One group goes to medical school, while another is drawn to programs in health or business administration. Not only are they individually different to begin with, but their professional experiences tend to reinforce these differences.

Practicing physicians engage in diagnosing and treating disorders in anatomy and physiology. They identify with their profession, focus on short-term results and learn to autonomously make many of the decisions intended to promote patient well-being.

By contrast, successful administrators focus on building support for organizational objectives. They often identify with their organizations while participating in long-term projects demanding both delegation and collaboration.

Over time, initial differences continue to grow as both groups tend to socialize with those who are similarly focused, draw support from their colleagues and place greater value on professional or organizational rewards. Given their differences in education, socialization, values, interests and work habits, frequent conflicts between the viewpoints of physicians and administrators are not surprising.

Simply noting and marveling at these differences is no longer sufficient. As large powerful forces such as government, payers, patients and competitors demand that health care organizations turn out more with less, both physicians and administrators feel the pressure.

Since both are responsible for health care outcomes, focusing energy on working together to produce needed results is ever more critical. Aligning objectives, attitudes and behaviors can be difficult if people don't have similar histories, learnings and perspectives.

Beyond developing an understanding and a respectful appreciation of both realities, what can be done to successfully move forward together?

Who should be in control?

Many physicians and administrators typically believe they must be in control and the other group must be managed if quality health care is to survive.

We often hear statements like:

* Since the administration seems to have little understanding and appreciation of our patients' clinical needs, we physicians must band together and continue to point out the problems while demanding necessary changes.

* Physicians don't understand the impact of their choices on costs. They also don't understand the need to accumulate capital in order to be a long-term, financially viable community resource. We administrators must control those physicians to the best of our ability.

Neither of these perspectives leads to enhanced collaboration. The harder administrators push on physicians, the harder physicians push back -- and vice versa. Eventually, people who are critical to success simply stop coming to the meetings or withdraw completely from the organization, providing further ammunition in the downward spiral of blame and control.

In the end, this defensive cycle of blame and control drains the lifeblood from our health care delivery process, while further frustrating customers who hold both physicians and administrators jointly responsible for high-quality, cost-efficient health care results.

An alternative exists. It requires managing the behavior of those over whom we have control--that is, ourselves. It also requires suspending attempts to control those who are, for us, unmanageable.

We may need to look in a new place for answers if our old search is not getting us the results that we want.

Identifying the biggest obstacle to success

Please take a moment and identify your single biggest specific professional problem.

Write down the problem in one or two sentences. If you had a magic wand and could get rid of one problem only, what would it be? Don't say something general like "people" or "communications." Be specific. When adult professionals are asked this question, they often respond by saying things such as:

My biggest problem is that:

* "They" never give me accurate data.

* Physicians/administrators just don't understand.

* Physicians/administrators don't keep their commitments.

* We don't have enough staff.

* Physicians/administrators just don't listen.

Statements like these may sound familiar and even legitimate. The problem is that they limit your chance, as a leader, to effectively move forward because they require the other group to straighten out first.

The people making such statements acknowledge no responsibility for contributing to the problems, challenges and conditions.

If you really believe that others are the source of the biggest problems facing you, it leaves you powerless to improve results. Only by a shift in perspective can you, as a leader, assume sufficient power to identify new alternatives and break through the barriers that constrain success.

Answers that offer the possibility of progress sound more like:

My biggest problem is that:

* I have been unable, so far, to convince the administration that I need to know more about

* I am not reaching my people.

* My planning about this matter has not been adequate.

* To date, we haven't reached our clinical outcome goals.

* I have not yet communicated my vision with sufficient clarity to win physician support.

Many people are more familiar and comfortable with the first set of responses. There are many advantages to the "victimhood" reflected in the initial answers. When you interpret the world as doing it to you, problems are beyond your control.

This allows you to see yourself as a good guy and the others as bad guys. It allows you to protect your ego, at least in the short run. Victimhood absolves you from responsibility. Since you had nothing to do with creating the problems, no one could reasonably expect you to correct them.

In addition, you often get sympathy, which at least feels good.

Regaining control

Unfortunately, victimhood has negative consequences.

When leaders claim that the past was out of their control, they are also abdicating the power required to impact the future. If you were powerless in the past, then you are still powerless in the future. If it just happened to you before, it could just happen to you again.

An alternative leadership style depicted in the second set of responses flows from the assumption of responsibility.

Responsibility is not to be confused with blame, shame, guilt or praise. It is simply an indication that you, as a leader, claim that you are powerful enough to impact events around you. It is the recognition that you are able to respond to events in a manner that impacts long-term outcomes. Responsibility requires a willingness to acknowledge that, by your actions or lack of actions, you influenced past outcomes and have the same power in the future.

An assumption of responsibility suggests that, rather than simply blaming physicians or administrators and hoping they will fix your problems, you are willing to constructively participate in creating collaborative solutions to current challenges.

Many people would like others around them to behave in this manner, but responsibility as a leader requires that you take the first steps by altering your behavior to show the way.

But are you really responsible?

This is not a very helpful question. In the end, fighting about who was right and who was wrong will do little to improve current conditions. Focusing your energy on blaming and controlling others who do not share your views will contribute little to solving current problems.

No one group can solve our health care problems alone. The real opportunity for you as a leader comes by assuming a perspective of responsibility that allows you to effectively work with others to jointly create the future that you say you want.

Health care application examples

When you are lost in the great outdoors, it can be useful to climb to higher ground to get a look around. The same is often true when we are locked in a confrontation with others.

It is valuable to review the situation from the higher perspective of assumed responsibility. For example, a physician recently shared the following experience:

Dr. Rogers noticed that when he was in a bad mood, the people in his office often seemed to be in a bad mood. One day he asked his office manager why every one seemed so negative that day. Her response surprised him.

She said each morning the staff would look out the window as he was approaching to see what kind of mood he was in before he even entered the office. Then they followed his lead. He set the tone for the office before he ever came in the door.

Now, before he leaves his car, the doctor says he takes in a few deep breaths, smiles and enters his office area greeting people with cheery "hellos."

The results have been astonishing. More importantly, he has come to recognize the power he has in influencing the conditions around him.

Until he recognized that he was contributing to the attitudes in his office, he was powerless to improve these outcomes. Once he acknowledged his impact, he was in a position to experiment with alternatives until successfully achieving the results he desired.

Acknowledging your contribution to current conditions and what you're willing to do in order to improve the situation can have a powerful impact even under very difficult conditions.

Another example

Several years ago, physicians employed by an HMO held a retreat to share their long-standing, deep-seated anger toward their CEO.

Knowing that the situation was explosive and the organization's future was at stake, the CEO started the meeting by indicating that he would stay as long as was necessary to hear and understand each of their concerns. He then acknowledged several actions he had taken that, while well intentioned, contributed to the current state of conflict between physicians and administrators.

For example, he said he now realized that limiting technological investments in several of the clinics had a negative impact on medical outcomes and damaged his relationship with the physicians.

He then added that the necessary resources would be made available during the next week to begin to rectify this situation.

While this one act on his part was clearly not enough to re-establish the desirable levels of trust and collaboration among physicians and administrators, it did set the tone for the remainder of the meeting so that constructive conversations could occur.

What options are available?

It usually does look to most of us like the other people are wrong. Those physicians/administrators really don't understand. This may be true. They may well not understand or agree with your perspective. The relevant question is what to do under these circumstances.

If you really choose to operate as a leader within your profession or organization, you may need to take responsibility for developing the trust necessary to work together with those you need to succeed.

Building trust requires a willingness to understand others' views and develop mutually acceptable solutions. Trust cannot be demanded or required.

Building trust involves developing a shared understanding of reality rather than telling others over and over again how you see things. It requires an investment in understanding and demonstrating a respect for the views of others with whom you need to partner in order to achieve your desired outcomes.

Why should you take the lead in understanding their views? Why is this required of you when their position seems so unreasonable?

Because you are the leader.

RELATED ARTICLE: Test Your Level of Responsible Behaviors

Here's a short set of questions that lets you evaluate the degree to which your leadership has demonstrated responsible behaviors. Collect candid, untraceable information from the relevant perspectives of those with whom you work (physicians, top, middle, and lower level administrators, nurses, and a cross section of additional employees). Unless the results are consistently positive, it may be appropriate to take steps now to make the transitions necessary to expand the trust and collaboration you receive from those whose support you need to succeed.

Characteristics of Responsible Leadership

Please describe your leadership using the following statements.

Respond to each statement by indicating how frequently it is true on a scale ranging from Never (1) to Always (5).

When working with those who hold views different than my own, I:

a: Acknowledge the importance of their views by listening carefully to them, even when I disagree with what they are saying

b: Demonstrate my thorough understanding of their ideas to their satisfaction prior to asking that they understand my views on an issue

c: Clearly acknowledge the positive value of those aspects of their positions with which I can agree

d: Ask questions in order to fully understand their underlying assumptions

e: Ask questions in order to fully understand what is most important to them

f: Restate my understanding of their views to ensure that they know I grasped their positions

g: Acknowledge my contribution to creating areas of current concern (rather than blaming them for all the difficulties faced)

h: Provide constructive recommendations in language they find meaningful, acceptable and relevant

i: Openly specify areas remaining that are still of concern or unclear

Any score below 3 demands serious consideration, if not action. For example, effectively demonstrating understanding rather than demanding that you first be understood will do much to open communication.

Acknowledging your co-workers reality by listening carefully to their views, demonstrating you understood them, acknowledging those aspects of their positions that you agree with and seeking to understand their fundamental assumptions can open the door to trust and collaboration.

ACPE Resources

Bring Ed O'Connor to your organization for an Onsite Educational Program.

Call 800/562-8088 or visit www.acpe.org./onsite for more information.

Edward J. O'Connor, PhD is a principal with the Implementation Institute, a professor of management at the University of Colorado at Denver, a courtesy professor of management at the University of Oregon and a member of the faculty for the American College of Physician Executives and the Kaiser Consulting Network. He can be reached by calling 303/573-1273 or by e-mail at [e-mail].

Michael H. Annison is president of The Westrend Group in Denver, Colo., a member of the Kaiser consulting network and co-author of Trust Matters --New Dimensions of Health Care Leadership and author of the award-winning Managing the Whirlwind -- Patterns and Opportunities in a Changing World. He can be reached at 303/321-6211 or by e-mail at [e-mail].