ADR in Healthcare: The Last Big ADR Frontier?

Previously Published in: ACResolution, The Quarterly Magazine of the Association for Conflict Resolution, Spring 2003.

Introduction

You are probably saying to yourself “What a strange title.” This seems especially true when you consider that dispute resolution and conflict management (DR/CM) practitioners are a fairly flexible, adaptable and imaginative group. Surely there will be lots of new “frontiers” left for us to conquer in the future?

But when you stop and think about it, there is little doubt that healthcare is one of the last major fields to consistently show interest in the possibilities of using DR/CM techniques and experience to resolve disputes and prevent conflict. Why is this so, and what can we do about it?

What’s So Special About ADR in Healthcare?

It is helpful to recognize that healthcare, as a social system, has a number of characteristics that make it less amenable to using DR/CM approaches to solving problems.

To begin with, healthcare has been described as a complex adaptive system. This is largely characterized by fluid linkages, flexible rules heavily reliant on system history, constant change, a huge volume of data, and multiple feedback loops but limited access to others’ information. Typically that kind of system is prone to generating more errors and to being more innovative than other types of social structure. The complex nature of the system makes it harder to understand – for system participants as well as conflict resolvers – the various components, how they inter-relate and the sources generating conflict.

Another particular characteristic of healthcare is widespread inequalities and imbalances of power, knowledge and control. Few other social systems have so many imbalances. The inequalities are obvious between healthcare providers and patients, but are also present between groups of providers (doctors, nurses, and others), types of providers (primary care versus specialist care or curative versus preventive orientation), between payers and management as well as between management and providers. The list could go on even further.

Another feature of healthcare is the widely divergent “cultures” and value-systems of the various professional and non-professional groups working within the system. Once again, it is relatively easy to see that patients and their families will look at a clinical problem through very different eyes than their healthcare providers do. But it is also true that the general orientation of physicians differs widely from that of most nurses. For instance, if we were to look at a healthcare error and ask how it might be understood by a physician (even different physicians with different specialties), a nurse, a social worker, a pharmacist, a risk manager, a CEO, a lawyer, and a patient, we would quickly see that the perspectives would be very different. While the parties to disputes usually bring differing values and outlooks to the table, it is unusual to find such a variety of people affected with such widely divergent views, many of which are based in their training and institutionalized by cultural support.

Identifying the parties who should sit at the table is also a major challenge. This is especially true when some of the parties are particularly reluctant to participate and others are routinely “invisible.”

At the same time, some of the qualities the disciplines share add a level of complication for conflict resolvers. Healthcare professionals tend to strongly link their identities to competent practice of their profession, to hold a sense of community that does not include those outside healthcare, and to be acutely aware of priorities competing for their time.

Taken together, these features and others generate a special situation where it is most unusual to find a simple straightforward two-party conflict, and sources of resistance are many.

Getting started : Overcoming Resistance (a sort of “walk the walk”)

Many conflict resolvers have asked the question “How can we get started in the healthcare field?” The simple answer, as in a number of new fields we approach, is to invest a lot of leg work, talking, and patience and to offer trainings to build capacity in the professionals and an appreciation for when complex disputes require our help. Additionally, it may take a willingness to adapt DR/CM processes to fit the particular needs of these professionals.

A system that is prone to generate errors should welcome DR/CM practitioners with open arms, right? It doesn’t seem so and one of the simple answers is that our work is not well understood. The need continues for us to take on the role of DR/CM “missionaries” for some time to come.

There are widespread misconceptions, even at the CEO level, about our field and our work. For instance, in one large hospital, we were confidently told that mediation was not needed for their problems, reflecting the idea that a mediator is someone who steps in at the eleventh hour to settle a nasty labour dispute. You all may have similar stories. We need to do some very basic educational work to explain our field and its concrete benefits to healthcare. With the current emphasis on gearing up major patient safety initiatives, the nationwide nursing shortage, rapidly increasing medical malpractice premiums leading to walkouts and practice or service closures, and financial pressures from many directions, this seems a particularly opportune time to make the case for the yield generated by an investment in DR/CM.

Particularly because of intense competition for time and resources, and clinicians’ and administrators’ tendency to want to manage all affairs themselves, offering trainings is useful work and a means of “missionary work,” at the same time.

There are a number of specialized venues in which to offer your services on a voluntary basis to build familiarity. DR/CM practitioners should offer to speak at clinical rounds, which are usually held on a weekly basis in most large institutions. Offer as well to speak to health disciplines students about the DR/CM approach to settling disputes. Contact hospital HR departments, where there is usually a fairly good understanding of our work, albeit restricted to employee/employer conflicts. Seek to do a survey – of the types of conflicts and methods of resolving them in a given facility or institution. Speak to professional societies, and approach them to consider offering mediation as a member benefit. You may not get paid in these endeavours, but you will make contacts.

If there is a need for hospital leaders to become educated about our work, there is an equal need for many DR/CM practitioners to better understand some of the special characteristics of the healthcare system and professionals. Some of them are described very briefly above. There are many listservs, professional societies, and journals geared toward the many healthcare sectors and disciplines; reading them will give you a sense of context and interests, in addition to the technical information.

Similarly, participating in trainings alongside healthcare practitioners is a chance to gain deeper insight into their pressures, objectives, and communication methods. The pioneering course in this regard has been offered by Harvard School of Public Health (the PHCNCR directed by Lenny Marcus). Other organizations are making this opportunity available continent-wide (for example, Curing Conflict in the USA and Resolving Conflict in Healthcare in Canada); different programs are geared toward different disciplines (clinicians, administrators, etc.), and have varying levels of time and financial commitment. If DR/CM practitioners want to earn work in the healthcare field, they must be willing to learn more about the specific nature of healthcare so they are well-prepared to provide a good service.

Finally, we need to work together to create a vibrant place to learn and exchange ideas and to strengthen our abilities to provide high quality DR/CM services in the healthcare field. This will help develop momentum that will be helpful to each of us in our individual initiatives to introduce ADR to healthcare.

Future Steps to Develop the Field

There are a number of things that each of us can do to help gain acceptance and recognition for the use of ADR in healthcare.

We must become adept at building alliances. Collaborative partnerships among ADR solo practitioners or firms allow flexible responses to demand for projects requiring more manpower or specialized expertise. An obvious alliance is with consumer and advocacy groups who, with similar education about ADR benefits, can bring pressure on various sectors (insurers, hospitals, doctors’ offices, government, accrediting agencies, national organizations) to fund and offer ADR. Interestingly, risk managers also show an increasing interest in facilitated discussion.

The growing movement for patient safety is a natural ally; its advocates share many of the same concerns, but are often not very knowledgeable about DR/CM techniques, practices, and training. For example, ADR professionals are well-prepared to train medical staff in the difficult task of talking with patients and families medical errors, a mandate that sometimes has devastating effects on both patients and clinicians. In more complex cases, we are surely well-placed to facilitate those discussions. Patient safety demands an entire culture change in favour of open discussion of vulnerable topics in hopes that it will lead to prevention; here, too, is a natural fit for conflict resolvers to help administrators determine how to create that environment.

Find out if your local hospital, or the system it belongs to, has a patient safety coordinator, and which administrators have a particular commitment to the effort. Visit the patient safety website of the NPSF or the AHRQ. Attend the excellent meetings organized by the National Patient Safety Foundation and local organizations and learn the specifics of how these problems arise and the solutions people are proposing. You will find many concrete examples of situations for which your skill sets are a perfect fit.

To convince healthcare leaders that we can make important contributions, we must develop a persuasive economic argument for using ADR in healthcare. One of the authors was recently involved in a mediation concerning the hospital privileges of a physician. Prior to the mediation, the direct legal costs to all parties exceeded $100,000 and the associated administrative costs added another $75,000. The mediation (at a cost of just over $10,000) was apparently successful and has avoided further legal developments, the average total cost of which would easily exceed another $250,000.

ADR and healthcare professionals alike clamour for data. It appears that, to date, it has only been generated in isolated pockets. If we look carefully, though, we will find that others have made some of the arguments for us. For instance, the experience of a large VA hospital in Kentucky showed that early and full disclosure of medical errors to patients and their families did not have the expected effect of increasing costs. In fact, most patients were astounded to be treated fairly and with respect, and responded in a fair manner themselves. As you approach potential clients, use the figures that are out there, and make clear the analogies to other fields (that is, be ready to counter the first response, which is generally, “health care is different”).

Think about generating this data in your cases; this can be formal or informal. We too often neglect to ask questions about the economic aspects of the problems we are helping people resolve. If you are designing any kind of system, build in a measurement tool. And just as we encourage clients to find means to expand the now-cliché pie, sharing these data will help all healthcare ADR practitioners to shift the field’s expectations toward ADR as a routine practice. Often the economic bottom line may be the most influential argument at the outset. Later, the advantages in terms of human resource management will be recognized.

Finally, DR/CM practitioners often feel too busy helping people solve their problems to write about their experiences. Many DR/CM practitioners are doing interesting and challenging things in the healthcare field. We must learn to talk the talk (or, more appropriately, “write” the talk). We need to share our victories and our defeats with each other, both in case studies and in methods of overcoming resistance.

Conclusion

Many recognize the huge need in the healthcare field for DR/CM techniques and experience. There are several excellent articles in the May issue of ACR magazine that address some of the challenges facing us and there are dozens more that could be written. We will all benefit by sharing our experiences, starting to build energy and enthusiasm, generate ideas, and support each other in taking on this sometimes daunting task.

                       

Ginny Morrison

Ginny Morrison works with health care organizations and prison systems to make collaboration practical, improve patient safety, and advance culture change. She applies conflict management principles to patient safety implementations, operational issues, clinical team and research disputes, unanticipated outcomes discussions, quality improvement efforts, and bioethics consultations. She publishes on these topics… MORE >

                       

Rob Robson

Dr. Robert Robson is Director of Patient Safety at the Winnipeg Regional Health Authority and is responsible for coordinating patient safety programs and initiatives throughout the region. He has recently been named to the Board of the Manitoba Institute for Patient Safety and served on the Minister of Health’s Emergency… MORE >