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The key to collaboration is to accept and manage conflict.

A group of general surgeons, seeking to increase revenue, begins to perform endoscopies on their patients and to compete for procedure time with the current group of gastroenterologists who perform the majority of endoscopic procedures in the hospital's outpatient ambulatory center.

The general surgeons and gastroenterologists up to this point have had an excellent relationship. The surgeons referred to the gastroenterologists for endoscopic procedures, and likewise the gastroenterologists referred to the surgeons for operative procedures.

Angered by the likelihood of new competition from the surgeons, the gastroenterologists stop referring to the surgeons and threaten to open their own outpatient facility.

The surgeons, in turn, stop referring their patients to the gastroenterologists. Heated exchanges between members of both groups ensue. The president of the medical staff, upon hearing of these exchanges believes the issue is between two private groups and decides not to intervene.

Likewise, the vice president for medical affairs also decides not to intervene. She believes the issue is nothing more than the usual disagreements that occur between physician practices and given enough time will just blow over.

The unrest continues to escalate. Flaring tempers between the two physician groups begins to impair the overall functioning of the outpatient center. The gastroenterologists move forward with their plans to open their own facility.

When the president of the medical staff and VPMA attempt to meet with the two physician groups, they refuse. Unable to get the groups to discuss the issue, the hospital attempts to offer some concessions to both groups. It is too late.

The gastroenterologists open their center. The hospital loses 70 percent of its endoscopic procedures, resulting in a significant decline in its operating margin. Seeing what has happened, a group of orthopedic surgeons begins to threaten opening their own center.

Common occurrence

If this scenario sounds familiar, it is because it is happening at hospitals around the country. Conflict is an every day part of our personal and professional lives. Given the frustration facing physicians over reimbursement and regulation it is no wonder physicians are losing their previously collaborative relationships.

Is there a way to regain and maintain collaboration? Jeff Weiss and Jonathan Hughes (1) argue that to maintain and foster collaboration an organization must accept and actively manage conflict. How does a physician leader actively manage conflict?

The first step is to "stop the bleeding" by intervening to prevent the conflict from escalating (Figure 1). However, it is a natural tendency for us to try to avoid conflict. We don't believe the issues involve us or that we do not have the authority to intervene.

Ignoring the conflict or believing it will go away over time does nothing more than to allow issues to remain unresolved and emotions to escalate. The only goal at this early phase of conflict is to prevent further instability.

It is important to realize that intervening is not the same as attempting to mediate the conflict. Intervention involves distilling a culture throughout the organization that accepts conflict, understands the consequences of not intervening and does not accept avoidance and inaction when conflict inevitably occurs.

The next step in actively managing conflict is to decide if you are adequately positioned to mediate the conflict. The ability to mediate a conflict requires knowledge of the issues and credibility with the parties in conflict.

Authority and title do not by themselves qualify an individual to act as a mediator. The authority must not only be recognized, but it must be relevant to the conflict and parties, as well.

If after intervening you honestly believe your knowledge, credibility, and authority are not relevant to the conflict, your job is to find someone who is relevant to mediate. Failing to accept the role as a mediator or finding the appropriate individual to act is no better than not intervening in the first place.

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Once you have accepted the role as mediator, your next step is to gain a better understanding of the conflict. Why did it occur and what are the issues underlying the conflict? Is it the competition between the two groups underlying the conflict or does it involve deeper issues?

This is accomplished by identifying the party's interests, and once identified begin to prioritize them. What trade-offs would they be willing to make to gain resolution of their most important issues?

As Weiss and Hughes point out, you must get to the root cause of the conflict, rather than focusing on the symptoms. In addition, everyone in the organization must understand and develop criteria for making trade offs. This further fosters cooperation and collaboration, despite active conflict.

Ready to burn

What if the parties in conflict refuse to cooperate? If one or the other parties believes time is on their side, they may attempt to delay resolution. If this occurs, the mediator must create a "burning platform" to get them to the table.

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For example, if the mediator provided the gastroenterologists with information regarding The Center for Medicare and Medicaid's (CMS) intention to rebase diagnosis-related group and physician reimbursement and substantially decrease payment to specialty centers and specialty physicians, they might be willing to explore options beyond opening their own center.

Likewise, if the surgeons are given data showing the potential loss of income if their referral base from the gastroenterologists continues to decline, they might be willing to explore options to increase revenue without jeopardizing their referrals from the gastroenterologists.

In both cases, each group's best alternative to a negotiated agreement (BATNA) is reduced with this additional information, creating an imperative for them to reach a resolution.

As solutions are explored, it is important the mediator not be seen as "the bridge" to mediate all further conflict. The parties must deal directly with each other, so when conflict arises in the future, the parties in conflict will have the means among themselves to resolve it.

Finally, when an agreement is reached the mediator must ensure that expectations are well established. In addition, the process should be transparent to prevent any push back or misunderstanding from both constituents and individuals outside of the direct conflict but who have been impacted by it.

Conflict is inevitable. However, by devising and implementing a common strategy for intervening and mediating conflict, and in doing so incorporate conflict resolution into the day-to-day processes of an organization, it can actively manage its conflict. In doing so, it will create a culture of cooperation and collaboration.

David P. Tarantino, MD, MBA, is executive medical director of Shock Trauma Associates, P.A., a 50+ physician, multispecialty practice associated with the University of Maryland School of Medicine. In addition, he is the chief executive officer of The MD Consulting Group, LLC, a health care management consulting firm in Baltimore. He can be reached by phone at 410-328-2036 or by e-mail at mdcg@verizon.net.

References

1. Weiss J and Hughes J. "Want Collaboration?: Accept and Actively Manage Conflict." Harvard Business Review; March 2005

By David P. Tarantino, MD, MBA

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Title Annotation:conflict resolution
Author:Tarantino, David P.
Publication:Physician Executive
Geographic Code:1USA
Date:Jul 1, 2006
Words:1164
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