1. Addressing chronic conflict and problematic behaviors in a group practice Anthony L. Suchman, MD, MA Jody Hoffer Gittell, PhDElsie Mainali, MD, PhD Healthcare Consultancy, McArdle Ramerman Center, Rochester, NYHeller School for Social Policy and Management, Brandeis University, Waltham, MAVirginia Beach, VA Background Current Condition AnalysisTargets Implementation Results/Follow-up In a subspecialty intensive care unit with 60 hospital staff members and a 5 person physician group, conflict between the physicians was compromising quality by disrupting the continuity of care, hindering communication and creating a tense work environment. shift-work mentality (“you just do your work and go home”); collaborative interaction limited to sign-out rounds; doctors want more cohesiveness perception of “immature” or “petty” behaviors on the part of others, dismissed by some as just “personality differences” little awareness of negative impact on quality or the negative perceptions of the practice throughout the hospital conflict-averse leader, no systematic accountability; doctors want stronger leadership new practice director hired from outside, about to take over Overall RCS scores PhysNurses (day) Nurses (night) RT (day) RT (night) OT/ PT Unit Sec’ty Case Mgrs Nurse Mgrs Overall Physician3.704.023.833.893.673.653.563.583.363.71 Nurses (day) 3.874.424.304.154.084.204.294.053.704.04 Nurses (night) 3.594.184.434.093.952.404.233.144.083.83 OT/PT3.284.333.502.813.214.573.904.103.383.51 Unit Sec’y3.774.434.293.33 3.434.573.573.863.82 Case Mgrs3.804.253.333.932.614.004.364.574.073.86 Nurse Mgrs 3.093.86 3.29 3.143.572.864.573.37 Overall3.734.274.173.953.803.854.143.843.813.88 Dimension of Relational Coordination Avg - all work groups Phys1Phys2Phys3Phys4Phys5 Frequent Communication 4.473.924.624.573.744.72 Timely Communication 3.813.754.003.773.223.85 Accurate Communication 3.974.034.143.853.693.97 Problem-solving Communication 3.632.763.893.613.333.41 Shared Goals3.853.503.733.773.363.74 Shared Knowledge 3.533.613.623.543.313.53 Mutual Respect3.603.033.653.412.973.53 Overall Relational Coordination 3.883.583.983.843.443.87 Number of Respondents 393839373936 Cronbach’s Alpha.78.79.52.76.83.74 Relational Coordination survey scores: No collective identity (I >> we)Shared purpose, vision and goals Inadequate time together as a practice to develop connections and discuss clinical approaches Practice meets periodically to review results, develop pathways and conduct quality improvement projects Poor insight about how others see self and practiceAccurate individual and collective self-assessment based on data Inadequate communication skills to work with difference Skills for emotional self-management and managing difference as a resource Extreme individual autonomyInterdependent autonomy; co-created individual performance goals Conflict-averse, disengaged leadershipEffective leadership to create cohesiveness, alignment and accountability 360 feedback for individuals and practice based on interviews and RCS Coaching for practice leader Individual feedback reports Practice retreat for teambuilding, skills development and dialog to create collective vision and expectations 1:1 meetings with director q 3 wks to develop and track individual performance goals PhysNurses (day) Nurses (night) RT (day) RT (night) OT/ PT Unit Sec’ty Case Mgrs Nurse Mgrs Overall Physician (6, 5) 3.70 4.22 4.02 3.86 3.83 3.89 4.03 3.67 3.89 3.65 3.49 3.56 3.83 3.58 3.71 3.36 3.40 3.71 3.92 Nurses (day) (12, 10) 3.87 3.97 4.42 4.30 4.20 4.15 3.87 4.08 3.42 4.20 4.07 4.29 3.97 4.05 3.82 3.70 2.85 4.04 3.88 Nurses (night) (12, 6) 3.59 3.90 4.18 4.04 4.43 4.39 4.09 3.82 3.95 4.07 2.40 3.43 4.23 4.11 3.14 3.82 4.08 4.18 3.83 3.99 OT/PT (3, 0) 3.28 NA 4.33 NA 3.50 NA 2.81 NA 3.21 NA 4.57 NA 3.90 NA 4.10 NA 3.38 NA 3.51 NA Unit Sec (1, 1) 3.77 4.00 4.43 4.00 4.29 4.00 3.33 4.00 3.33 4.00 3.43 4.00 4.57 4.14 3.57 4.14 3.86 4.00 3.82 4.02 Case Mgrs (2, 0) 3.80 NA 4.25 NA 3.33 NA 3.93 NA 2.61 NA 4.00 NA 4.36 NA 4.57 NA 4.07 NA 3.86 NA Nurse Mgrs (1, 1) 3.09 3.69 3.86 4.14 3.86 4.14 3.29 3.71 3.29 3.71 3.14 3.71 3.57 4.14 2.86 3.71 4.57 4.17 3.37 3.84 Overall (39, 26) 3.73 4.10 4.27 4.19 4.17 4.19 3.95 3.98 3.80 3.87 3.85 3.90 4.14 4.07 3.84 3.86 3.81 3.55 3.88 4.04 One physician was unable to meet individual performance goals and left within 2 months. Each of the other 4 physicians improved their individual RCS scores. The practice began to meet weekly, created clinical pathways and started QI projects. At a follow-up retreat 6 months after the first one the practice made plans to improve service to internal customers and practiced the necessary communication skills. The RCS shows potential as a feedback tool and demonstrates sensitivity for tracking longitudinal changes in individual and group performance. Themes from preliminary interviews: