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Resolving and avoiding conflict with the professional staff.

Rising costs, tighter reimbursement policies, and increased competition have placed hospitals in difficult, often precarious, financial circumstances. As hospitals evolve in response to these pressures, power is shifting toward hospital management and away from the professional staff. This shift has tended to create an adversarial relationship between management and the professional staff--physicians, nurses, social workers, and others who provide medical care and critical support services. In many hospitals, this adversarial relationship undermines cooperation, interferes with decision making, and militates against efforts toward efficient utilization of the hospital's resources. In other hospitals, the relationship between management and the professional staff is characterized by overt hostility that occasionally generates a cataclysmic confrontation, a crisis.

It is common for hospital executives, especially those who have not practiced medicine, to interpret their conflicts with the professional staff as resulting primarily from the staff's self-interested efforts to protect its "turf/" The element of professional self-protectiveness is, to be sure, a recurrent feature of such conflicts, no matter what the underlying substantive issues may be. In this era of intrusive regulation, health professionals--especially physicians--are extremely assertive in protecting themselves against further erosion of their traditional authority and control over their own work (and finances). Consequently, the professional staffs concern for its professional prerogatives may easily become a sticking point in any conflict between it and management, distorting or even preventing further substantive discussions. Underlying the professional staff's efforts to preserve its authority and control, however, is a deeper source of conflict with hospital management. The professional staff perceives the hospital not as a corporation, but as an institution with a unique mission: providing health care to patients. Because this mission cannot be defined exclusively, or even primarily, in economic terms, it has a direct, adverse impact on how the professional staff perceives, and responds to, management; the quality of health care, not its economic productivity for the hospital, defines the professional staff's frame of reference. Except when the hospital's economic viability is problematic, the professional staff perceives itself as having little, if any, stake in the hospital's financial condition. From the professional staff's perspective, management policies intended to improve or protect the hospital's finances may do little more than distort the work environment and make it more difficult to provide health care.

The particularly human character of health care reinforces the professional staff's tendency to see central financial planning and decision making as anathema. Each member of the staff is primarily concerned with providing the best available health care to each individual patient. Moreover, because patients are typically quite needy, both physically and psychologically, the professional staff's encounters with patients provide especially strong psychological incentives and rewards for identifying and addressing their individual problems. Overall institutional needs and circumstances are irrelevant to these tasks, and whatever interferes with them is unwelcome.

The professional staff sees the hospital in terms of its providing quality health care to each individual patient. In contrast, hospital executives see the hospital in terms of its financial and systemwide performance. Unless these divergent perspectives are effectively integrated to solve problems and formulate hospital policies, chronic conflict between hospital management and the professional staff is inevitable. The following case illustrates how, in the context of continuing problems and a poor working relationship between management and the professional staff, a disagreement concerning hospital policy can escalate into a major crisis having long-term implications for the hospital's development.

Case Study

A hospital routinely discharged ventilator-dependent patients from the ICU when intensive care was no longer required. Following the near death of one such patient, and after consulting with lawyers, hospital management instituted a policy that all ventilator-dependent patients would remain in the ICU. Management cited nursing staff shortages and inexperience as justification for the new policy. The medical staff, however, believed that the policy would lead to a misallocation of ICU beds and resented yet another intrusion by management into what it considered a strictly medical problem. The medical staff also blamed the nursing staff for providing inadequate care. The nurses, in turn, asserted that they were overworked and underpaid. They castigated the medical staff for its insensitivity and arrogance and blamed management for failing to provide training sessions for new nurses and continuing education for experienced ones. Despite encountering these unexpectedly strong reactions, management held firm to the new policy. Over the next three months, nursing staff attrition accelerated, and the medical staff's hostility and frustration produced explosive debates at the board level, forcing the hospital to drop its carefully considered plan to reallocate facilities and expand outpatient services.

As in most such such situations, the underlying causes of this crisis were complex. In the reaction of the medical staff, we see concern about hospital policies affecting the care of patients, about the quality of nursing care, and about the erosion of professional authority and physicians' control of their own work. In the reaction of the nursing staff, we see resentment about being treated as second-class citizens by physicians and about management's lack of commitment to maintaining quality nursing care and acceptable work conditions and compensation. In the actions of management, we see both a failure to address continuing problems and a narrow, myopic focus on economic and legal issues.

In retrospect, the crisis was simply waiting to happen. But how is the crisis to be resolved? And other than empty advice to address problems expeditiously and not let them get out of hand, how can future crises be avoided?

Crises typically trigger the disclosure of chronic, and sometimes unrelated, problems. If managers fail to address these problems, achieving a stable solution to the controversy will prove to be an elusive goal. The problems will continue not only to undermine management but also to affect morale, the quality of patient care, and the efficient operation of the hospital. Any attempt to resolve a crisis should therefore address both the immediate problem that triggered the crisis and the preexisting problems that brought the hospital to the point of volatility. The following seven-step process is specifically designed for this dual purpose.

Steps to Resolution


Tense confrontations typically polarize positions and prevent reasoned analysis and discussion. The crucial first step is therefore to disengage management and the professional staff from the immediate conflict. Defusing the emotion tension of a direct confrontation enables all interested parties to regain their intellectual bearings.

Untangle. Once management and the professional staff have been disengaged, they each must identify and discuss the sources of their dissatisfaction. What previously appeared to be a tangle of intractable grievances will yield, with discussion, a number of discrete, well-defined problems.

Clarify. After the central problems have been identified, management and the professional staff must clarify their own goals and establish priorities. Unless both groups develop coherent conceptions of their goals for themselves and the institution, future joint discussions will lack specificity and focus.

Constrain. The hopes and expectations of management and the professional staff must be constrained by what is feasible in the real world. The hospital's professional culture and financial circumstances are especially important factors to consider at this stage. Management and the professional staff each must translate its previously defined goals into realistic alternatives that will form a framework for useful and productive discussion. Each must come to understand the various tradeoffs and compromises involved in the choice of one alternative over another.

Engage. After management and the professional staff have adjusted their expectations to reality, they are ready to engage in discussions covering the full range of issues relating to the crisis. Each discussion should have an agenda and a moderator whose primary role is to keep the discussion focused and moving forward. To engender present and future cooperation, both management and the professional staff must be induced to understand and appreciate the other's viewpoint.

Accommodate. Any stable agreement will require management and the professional staff to accommodate each other's needs. Agreement must be reached through a consensus founded on mutual respect, understanding, and recognition of the legitimate values and goals of all interested parties. Only such a consensus will produce the closure required for a stable solution to the controversy.

Implement. The process of implementing the agreement between management and the professional staff will vary from one hospital to another. At one extreme, implementation may involve extensive reorganization of services, departments, facilities, and so on. At the other extreme, implementation may require reltaively minor adjustments; periodic checks with management and the professional staff will suffice to determine whether implementation is progressing smoothly and as expected.

By addressing the professional staff's interest in working conditions and quality health care, as well as management's corporate interests, the above process leads to an understanding between management and the professional staff that enables them to work productively together within a financially stable institution. Ill feelings will dissipate and gradually be replaced by a renewed spirit of cooperation for mutual advantage.

Before any hospital uses the suggested process for resolving a crisis, two qualifications need to be made. First, the process has been separated into seven distinct steps primarily for analytical purposes; each step represents a genuine stage in moving beyond an emotion confrontation toward the implementation of a mutually satisfactory agreement. In the real world, however, hospital crises vary in complexity, in the degree of hostility between management and the professional staff, and in the range of issues that must be addressed. The speed with which a hospital would proceed through the stages--or, indeed, whether the entire process could be telescoped into three or four stage--will vary accordingly.

Second, the process would significantly benefit from the use of a trustworthly intermediary who can work effectively with both management and the professional staff. This person could, in fact, be a highly respected member of either management or the professional staff, but he or she would have to suspend completely his or her allegiance to either side for the duration of the negotiations. In general, a better though more expensive alternative would be to bring in a consultant or mediator with extensive experience working with health professionals. [1] In any case, the designated intermediary would help keep the process on track by transferring information between management and the professional staff (subject to the permission of each), by communicating preliminary responses from one side to the other, by serving as a moderator for the joint discussions, and by overseeing implementation.

The intermediary does not function merely as a facilitator, however. He or she would also serve as a sounding board and critic for both sides. In performing this role, the intermediary should continually encourage both management and the professional staff to consider their own priorities in the context of three overriding goals:

* Providing high-quality health care.

* Maintaining a financially stable institution.

* Creating and maintaining a work environment supporting the achievement of high-quality care and financial stability.

These goals provide the intermediary with a powerful lever in the negotiations; every member of management and the professional staff must acknowledge a commitment to them, lest he or she be accused of irrationality or bad faith. Moreover, as the intermediary induces management and the professional staff to focus on these goals, he or she helps those involved to see beyond their own immediate greievances to the larger, substantive issues that confront the hospital. In so doing, the otherwise neutral intermediary becomes the advocate of the hospital itself.

Management Strategies

Even when a crisis is effectively resolved and the hospital is set on a new course, management needs to address itself to creating and maintaining a cooperative, productive relationship with the professional staff. Three general strategies are recommended--the first drawing upon the above discussion of crisis resolution, the second relating to early identification of problems, and the third concerning management's approach to decision making. The first strategy requires that management, when it finds itself in conflict with the professional staff, assess the particular character of the conflict. An isolated or occasional conflict is, of course, unavoidable. But when conflict is recurrent or when a single conflict becomes refractory, expands in scope, or increases in emotional inttensity, it is time to wonder what else is going on. It is time for management and the professional staff to disengage, take a step back, and engage in broader discussions than those directly relevant to the immediate conflict.

The second strategy for creating and maintaining a cooperative relationship with the professional staff is directed toward the early identification of problems within the hospital. Hospital executives should meet regularly with department heads and other members of the professional staff having supervisory responsibilities to discuss new and continuing problems. These senior members of the professional staff can also be asked to regularly canvass the professionals who work under them. In this way, management can learn about, and begin to address, problems as they develop. Moreover, these discussions between management and the professional staff will serve to create a new sense of cooperative and mutual concern. (As an indirect ben efit, the discussions are an excellent means by which hospital executives can begin to educate the professional staff about management's own tasks and responsibilities.)

In making their inquires about problems within the hospital, hospital executives and senior members of the professional staff should remember that problems and their sources are sometimes not easily identifiable. In this context, open-ended questions are a particularly good means of encouraging reflection and discussion: "What bothers you about your work or about your relationships with other staff members (or divisions)?" "What in the hospital would you want changed?" "How can management better understand or address your needs, or help you address those of your patients?" Questions such as these will often lead quickly to identification of well-defined problems.

Especially as problems are just emerging, however, they may be experienced simply as distress, as grievances having no obvious source or object. A person knows something is wrong (or that something is interfering with his or her work) but cannot yet identify the precise nature or origin of the problem. Distress should be recognized as an early and reliable sign that a problem exists.

The third strategy for creating and maintaining a cooperative relationship with the professional staff concerns the approach management takes to its own decision making. Though many decisions by management have little, if any, impact on the professional staff, many others--e.g., those relating to the care of patients, to the allocation of resources, and to hospital development--significantly affect all or part of the staff. To make such decisions without considerable input from the professional staff is to court disaster. Unilateral decisions by management not only generate political problems, but also are likely to be less informed and less responsive to the legitimate needs of the hospital's professional staff. Soliciting information and advice from the staff--and carefully evaluating this input in the process of deliberation--defines the minimally acceptable level of staff participation. In general, the more collabortaively management's decisions are made, the more informed, reflective, and efficacious the decisions will be.

Continuing tensions between management and the professional staff have recently engendered some discussion of reorganizing or restructuring the professional staff. [2] This approach, however, disregards the source of the tensions. The underlying problem is not organizational or structural, but cognitive and attitudinal. Each group has defined its own interests too narrowly, and the resulting disparity in perceptions and goals has segmented the hospital community, left chronic problems unaddressed, and distorted hospital decision making. Both management and the professional staff need to acknowledge their common, obligatory goals: to provide high-quality health care, to maintain the financial stability of the hospital, and to create and maintain a work environment that promotes the achievement of both. These common goals, in turn, provide a framework within which management and the professional staff can work together to address the hospital's problems and chart its future.


(1) Parties to a dispute often fear that suggesting the use of a mediator will be perceived as a sign of weakness, failure, or incompetence. To avoid this problem and to expedite dispute resolution, it is helpful for management and the professional staff to enter into a standing agreement to bring in a mediator whenever a refractory conflict occurs.

(2) Various models have been suggested. For example, Shortell discusses the "independent-corporate," "divisional," and "parallel" models in "The Medical Staff of the Future: Replanting the Garden." Frontiers of Health Services Management 1(3):3-28, Feb. 1985.

Stephen Scher, Ph.D, JD, is a mediator and management consultant in Cambridge, Mass. He specializes in issues in health care organization and management, medical ethics, and health policy.
COPYRIGHT 1991 American College of Physician Executives
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Author:Scher, Stephen
Publication:Physician Executive
Date:Jul 1, 1991
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