1. Join the conversation! Our Twitter hashtag is #CPI2011. Transform Your Practice by Negotiating Change Take a “Walk in the Woods” Jay W. Lee, MD, MPH Christina Bell, RN Wendy Linderholm, PsyD Long Beach Memorial Family Medicine Residency Program Long Beach, CA

2. Objectives Recognize change resistance and fatigue when re-designing your practice Learn the difference between positional bargaining and interest-based negotiation Practice interest-based negotiation using conflict-based health care case studies Apply interest-based negotiation methodology to better manage change

3. Agenda 8:00-8:45aLecture 8:45-8:55aOverview of group exercise 8:55-9:15aBreakout groups for case scenarios 9:15-9:30aDiscussion/wrap-up

4. Who we are 8-8-8 stand alone community-based FMRP in the throes of practice alignment with larger health care delivery entities –Jay W. Lee, MD, MPH Assistant Program Director –Wendy Linderholm, PsyD Behavioral Science Director –Christina Bell, RN, MSN Clinical Operations Manager

5. IS THERE CONFLICT DURING ORGANIZATIONAL CHANGE?

6. COULD YOU LEARN TO BE BETTER AT RESOLVING CONFLICT DURING ORGANIZATIONAL CHANGE?

7. IS THERE NEGOTIATION DURING ORGANIZATIONAL CHANGE?

8. COULD YOU LEARN TO BE BETTER AT NEGOTIATING DURING CHANGE?

9. MOTIVATIONAL INTERVIEWING

10. 2 Forms of Resistance Issue Resistance Relational Resistance

11. What MI Does: 2 Steps Issue Resistance Relational Resistance Change Talk Commitment

12. What Negotiation Does: 2 Steps Issue Resistance Relational Resistance Enlightened -> Aligned interests Self -> Enlarged interests

13. INTEREST-BASED NEGOTITATION

14. TALK THE TALK POSITIONALBARGAINING Adversarial – Win/lose Appropriate Moral issue Competition Bully

15. TALK THE TALK INTEREST-BASEDNEGOTIATION Collaborative – Gain/gain AppropriatePreparedness Professional work Organizational issues

16. TALK THE TALK INTEREST-BASEDNEGOTIATION Collaborative – Gain/gain AccomplishConcerns-Fears Experiences Fairness Safe Zone

17. Conceptual Framework for PROBLEM SOLVING MULTI-DIMENSIONAL Uni-dimensional problem solving “Me for Me” Two-dimensional problem solving “Me against You” “Us together” Classicadversarialconflict Collaboration

18. PROBLEM SOLVING Systematically integrate the perspectives of many different people MULTI-DIMENSIONAL PROBLEM SOLVING

19. LEARNING AND “UNLEARNING” INFORMATION If it is difficult to learn something new, isn’t it all the more difficult to “unlearn” something upon which we have invested? What happens when we become “invested” in what we have learned, or in a particular solution? The problem of “unlearning”? Resistance to change

20. BARRIERS TO NEGOTIATING TEAMWORK How do you value what you “get”? Perceptions What you ‘fight” for? What you get “easily”? The value of the OUTCOME is linked to the PROCESS

21. WALK THE WALK ProblemSolution TYPICAL PROBLEM SOLVING WALK IN THE WOODS Contest “solutions” based on: Power – linkages, influence Ethics – interpretations of what is “correct” Resources – capacity to “force” the issue

22. WALK IN THE WOODS: A PROCESS OF CHANGE ProblemSolution Process Foster problem-solving by working with the multi-dimensional interests and motivations of the stakeholders. A SERIES OF STEPS TO MOTIVATE AND GUIDE INTEREST-BASED NEGOTIATION

23. WALK IN THE WOODS Problem Solution SELFINTEREST ENLARGEDINTERESTSENLIGHTENEDINTERESTS ALIGNEDINTERESTS

24. SeparateMotives SharedMotives INDIVIDUALMOTIVATION? OVERLAPPINGMOTIVATION?NEW MOTIVATION MOTIVATION? COMBINEDMOTIVATION?Dynamics of the process

25. WALK IN THE WOODS SELFINTEREST SELF INTEREST Who are the STAKEHOLDERS? What are their INTERESTS? Questions: Encourage ACTIVE listening – DIALOGUE DISTINGUISH legitimate self interests from the “selfish”

26. WALK IN THE WOODS ENLARGEDINTERESTS ENLARGED INTERESTS What are the themes of: AGREEMENT? DISAGREEMENT? How might issues be Questions: REFRAMED to create NEW OPTIONS & SOLUTIONS?

27. WALK IN THE WOODS ENLIGHTENEDINTERESTS ENLIGHTENED INTEREST What How would you BRAINSTORM? Questions: CATEGORIZE these ideas into “LISTS?” NEW IDEAS IMAGINE? can you

28. WALK IN THE WOODS ENLIGHTENEDINTERESTS ENLIGHTENED INTEREST Questions: “LISTS?” What is FEASIBLE? 1 2 3 What do we AGREE UPON? What can we do this…? WEEK? MONTH? YEAR?

29. WALK IN THE WOODS ALIGNEDINTERESTS ALIGNED INTEREST What are possible What does each stakeholder How might you redefine Questions: want to want to What is each stakeholder willing to MUTUAL “SUCCESS”? “GET”? “GET”? “GIVE”? GAINOPTIONS?

30. WHY “WALK IN THE WOODS” ? Negotiators focus on solutions: Negotiators focus on solutions: The “Walk” serves as systematic guide The “Walk” serves as systematic guide The “Walk” metaphor focuses attention on perspective & multi-dimensional aspects of the problem. The “Walk” metaphor focuses attention on perspective & multi-dimensional aspects of the problem. The “Walk” focuses on process toward solutions …for both leader (mediator) and participants “Leave the conflict; go someplace else”

31. WALK IN THE WOODS SeparateMotives SharedMotives INDIVIDUALMOTIVATION? OVERLAPPINGMOTIVATION?NEWMOTIVATION? COMBINEDMOTIVATION? Dynamics of the process What you seek to discover as the guide to process UNI-DIMENSIONALTWODIMENSIONAL MULTI-DIMENSIONALPERSPECTIVES NEWDIMENSIONS MULTI-DIMENSIONALSOLUTIONS

32. MOVE FROM STEP TO STEP AFTER MAKING REAL PROGRESS Problem Solution SELFINTEREST ENLARGEDINTERESTSENLIGHTENEDINTERESTS ALIGNEDINTERESTS Be flexible

33. GENERATING INFLUENCE & BUY-IN Get the right people to the table Involve them in creating solutions Gain their commitment to make the agreement succeed

34. Special thanks Lenny Marcus, PhD, & Barry Dorn, MD, MHCM Program for Health Care Negotiation & Conflict Resolution Division of Public Health Practice Harvard School of Public Health

35. OUR CHANGE EXPERIENCE

36. Overview of group exercise Groups of 4 Choose roles –Role-playing (1 physician, 1 nurse, 1 front office staff) –1 Timekeeper/Observer Goal is for everyone to role play and observe at least once Pay particular attention to the mechanics of negotiation and how it “feels” to negotiate Opportunity for feedback at the end of each session and at the end of the seminar 8:55-9:15a Breakout groups for case scenario –8 min per trio –Switch roles at mid- point –4 min for feedback/reflection

37. Case scenario: Staff Meeting It is now staff meeting. The issue of what to do with late patients is on the agenda. Just yesterday, a patient arrived 30 minutes late for their diabetes follow-up. This patient had been late before but not for every visit and relies on public transportation. Due to a recent change in the patient’s insurance, it took an additional 10 minutes to confirm eligibility. The nurse was notified of the patient’s arrival at that time. The physician was running about 15 minutes behind in their schedule but exited the exam room just as the front office staff member arrived at the nursing pod to discuss whether to allow the patient be seen or to reschedule. Everyone was aware that the patient is a brittle diabetic. Negotiate now. (Roles: physician, nurse, front office, timekeeper/observer)

38. WALK IN THE WOODS Problem Solution SELFINTEREST ENLARGEDINTERESTSENLIGHTENEDINTERESTS ALIGNEDINTERESTS

39. DISCUSSION AND WRAP-UP

40. CONTACT Jay W. Lee, MD, MPH Assistant Program Director Memorial Family Medicine Residency Program Direct: (562)933-0012 Mobile: (323)533-2503 Email: eejaywon@gmail.com Twitter: @familydocwonk

41. FEEDBACK Difficult getting to enlightened/aligned interests Important to identify a process leader/facilitator Interesting to see individuals solutions -> systems solutions Success = focus on patient as a team Plagued by niceness High emotion -> calm by using words to make points Patient must be focused part of discussion especially re: policies –Shouldn’t patient be a stakeholder? Be mindful of corporate stakeholders Problems/solutions lead to/linked to other problems/solutions Critical to identify other stakeholders Self-actualization important Empathy is by product of process Ok to work backwards Co-directed care Huddles important