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The Tipping Point: Managing Conflict to Create Culture Change in Health Care

The medical malpractice crisis continues to affect access to liability insurance for physicians, and access to physicians for patients. Congress cannot agree on tort reform measures. Patient safety continues to be a big focus for health care organizations, consumers, purchasing groups, and the government. Yet hospitals are having difficulty implementing patient safety goals and other required JCAHO patient safety standards such as disclosure of unanticipated outcomes. Research endeavors are continuing to uncover advances in medical treatment that can affect generations to come, yet patients have little understanding of the protocols and informed consent is called into question in many situations. Additionally, the communication between researchers and the clinicians who are administering the protocol drugs is disjointed and leads to errors that can affect the clinical status of patients. The federal government and purchasing cooperatives such as the Leapfrog Group are advocating for safer clinical practices and there is movement to tie reimbursement to quality outcomes. Implementation of complex information technology and practice model changes to meet these recommendations is creating conflict between physicians and hospital administrators.

The increasing pressure to work collaboratively and to develop high-functioning teams within the clinical setting is driving a demand for better communication skills and facilitative leadership models to meet the needs of changing health care organizations. These are just a few of the contributing factors creating a demand for a culture change in the delivery of health services in the United States. As with any culture change, there is conflict and discordance that can be costly and painful. Finding ways for managing these conflicts and moving forward toward a safer health system is imperative. Conflict management practices can be the “enzymes” which facilitate reactions that drive health care organizations toward improved outcomes and healthier organizational environments.

In his book, The Tipping Point, Malcolm Gladwell identifies the factors that have proven effective in creating a “social epidemic.” The spread of ideas throughout society is analogized to the spread of a virus. Connections can be identified that enable an idea to spread and reach a critical mass, or “catch-on” in such a way that the idea tips the culture into a new direction or changes the behavioral norms of a group. It is not uncommon to see this phenomena occur with products or pop culture icons who are mass marketed. But it is more than marketing and hype that is behind the creation of a true culture shift. Malcolm describes three characteristics that define how an epidemic occurs. These characteristics are: 1) contagiousness, 2) little causes can have big effects, and 3) change happens not gradually, but at one dramatic moment. The third characteristic is referred to as “the tipping point”- the point at which disparate localized outbreaks become a full-fledged epidemic.

This tipping point is impacted by the actions of a few individuals, the “stickiness” of the idea, and the context in which the change is occurring. Applying these principles to the idea of integrating the field of alternative dispute resolution with health care delivery can help to create a tipping point for the intentional development of complementary conflict management systems within health care. Contagiousness, as it applies to the spread of ideas, refers to the excitement, enthusiasm, and energy that gets behind an idea and spreads it from place to place. In a social epidemic contagiousness is driven by a few individuals (transmitters), who have the ability to create excitement and spread the idea through their own enthusiasm, charisma, and social connections. Key individuals within both the health care community and the ADR community can infect others by spreading stories about the benefits and outcomes of their experiences with managing conflict intentionally. This creates an excitement that is contagious for others who are looking for meaningful ways to decrease escalation of disputes and redirect resources toward providing care to patients rather than toward litigation and recruitment of new personnel. Developing databases related to cost savings, better patient outcomes, improved satisfaction among patients and providers, and decreased litigation claims also helps to feed the contagiousness of the idea while building credibility with those outside the social network of the “transmitters.”

The famous Victor Hugo quote, “Greater than the tread of mighty armies is an idea whose time has come,” sums up the second characteristic. The theory is that many small pockets of activity add up to have a bigger effect than the sum of the individual effects of each activity. The synergistic effect of multiple groups, organizations, professions, and government agencies working in separate capacities occurs when the ideas and information generated by each entity begin to link and form networks. The creation of these networks can begin to paint a picture of how things could be different. For many years, ADR practitioners, academic organizations, government regulators, legal scholars and practitioners, health care associations, and health care delivery systems have looked at ways for decreasing costs and claims related to bad outcomes. Organizational development and human resources professionals have worked on strategies for decreasing turnover and retaining experienced clinicians through improvements in the organizational culture. Consumer groups have worked to develop means for their members to better communicate with their providers and to participate in the decision-making that affects their care. These seemingly disparate activities are adding up to have a big effect on the advancement of ADR in health care across the United States.

Change is a constant force in health care. New regulations, fluctuations in reimbursement, changes in technology, changes in disease patterns, diversity in the patient population, and changes in delivery system structures all create a continuous pressure on the clinicians and administrators working to deliver care in their communities. With constant change, it can be difficult for a particular idea to rise above the noise and truly make a difference. When an idea does rise above the fray and take hold, it appears that the change happens overnight. Consider a star who becomes “an overnight success.” There are typically years of hard work and training behind the drama surrounding that point in time when the success is noticed and star status is achieved. Similarly, with the epidemic of an idea, there appears a point in time where a dramatic change occurs and thinking shifts as if almost overnight. The development of complementary conflict resolution systems in health care organizations is nearing this point.

The context in which an idea is received affects how people respond to the idea which in turn affects how the idea reaches a tipping point. Broad adoption of the idea creates a culture change as individual organizations integrate the new idea. Changes in the health care environment are having a negative impact on the ability of health care professionals to deliver care to patients and on the ability of patients to access and understand the care they receive. These environmental pressures are affecting the perceptions of health care leaders who are beginning to view conflict as a naturally occurring component of complex health care systems. This environmental impact (context) helps to create an understanding that conflict must be addressed in a deliberate way. Changing the environment requires a change in the culture of health care. The integration of skill development, collaborative teams, communication strategies, facilitative leadership, complementary dispute resolution processes, and dialogue among competing interest groups, are all means for accomplishing this culture change. The destructive impact of toxic work environments on patients and providers is the context in which those who manage our health care resources will start to take notice of what options are available for creating better environments for healing. As the awareness increases, the development of the field of health care conflict management will spread like an epidemic throughout the world. And those who are “infected” with the virus, will find themselves a part of an exciting and humanizing chapter in the historical evolution of the culture of health care.


The Tipping Point: How Little Things Can Make a Big Difference, Malcolm Gladwell, 2002, First Back Bay Publ., ISBN: 0-316-34662-4 (PB)


Debra Gerardi

Ms. Gerardi is a mediator and health care dispute resolution consultant and Chair of the Program on Healthcare Collaboration and Conflict Resolution at the Werner Institute for Negotiation and Dispute Resolution at Creighton University. Ms. Gerardi is a licensed critical care nurse with more than 15 years of clinical and… MORE >

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