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The Hidden Cost of Conflict Among Healthcare Teams

The conflict, low morale, dissatisfaction and disruption that often go hand in hand with a mismatch in culture carries with it significant costs that may not be immediately apparent.  However, they can be quantified.  Here are a few examples of calculations used to quantify the costs:

·         One study done by the American Management Association on the cost of conflict showed that a manager will spend between 20% to as much as 50% of his/her time dealing with conflict in the work place.  In one particular healthcare system, the cost of conflict in managers’ time alone calculates out to

45 Managers x $85K/year x 30% = $1.147 Million

·         The Gallup Organization calculates the cost of the loss of one employee at 6 times that person’s annual salary.

1 Nurse x $65K/year = $390K

·         A business analyst uses the following formula to calculate the cost of dissatisfied employees:

Number of employees in the organization	50
What percentage is dissatisfied? (for any reason)	20%
Motivation level of dissatisfied employees - (what is their productivity as a percentage of the productivity of satisfied employees or as an ideal employee?)	60%
De-motivated level of dissatisfied employee	40%
Average hourly salary of de-motivated employ	$25
Average number of hours worked per week	40
Dissatisfied employee weekly wage bill:
(20% of 50 employees) x ($25 x 40 hours)	$10,000
Dissatisfaction cost per week (40% x $10,000)	$4,000
Annual dissatisfaction cost (50 weeks)	$200,000

·         The loss of one highly productive surgeon because of dissatisfaction with the service provided by disgruntled and inefficient OR staff will have a significant impact on revenue.

·         A surgeon performing an average of 20 cases/month at an average of $900/case
will take $216K/year in revenue with him should he go to a competitor.
Over 5 years, the loss in revenue would total over a million dollars.

The Benefits of High Employee Morale

A study published in Fast Company, May 2001, “Maister Class: Transform Morale Into Money” by Jennifer Reingold found that a company could boost its financial performance by as much as 42% by raising employee satisfaction by 20%.  In comparing financial performance of global offices, the top 20% of these offices significantly outranked the other offices by scoring one particular statement regarding employee satisfaction higher than their counterparts: "Enthusiasm and morale are high."

Feedback is My Friend

A colleague sent me the following abstract that will appear in the May 2005 issue of Medical Education.

Sargeant J, Mann K, Ferrier S. Exploring family physicians' reactions to multisource feedback: perceptions of credibility and usefulness. Med Educ 2005; 39(5):497-504.
Purpose: Physician performance is comprised of several domains of professional competence. Multisource feedback (MSF) or 360-degree feedback is an approach used to assess these, particularly the humanistic and relational competencies. Research studying responses to performance assessment shows that reactions vary and can influence how performance feedback is used. Improvement does not always result, especially when feedback is perceived as negative. This small qualitative study undertook preliminary exploration of physicians' reactions to MSF, and perceptions influencing these and the acceptance and use of their feedback.

Improving Physician-Hospital Relations

I just read a great article by Dan Beckham - "Improving Physician Hospital Relations."  Beckham offers a list of suggestions that hospitals could easily adopt that would go a long way toward improving relations with their physicians.  I'm curious as to whether any of you physicians have more ideas to add to the list or whether hospital administrators have ideas you've used successfully and would be willing to share.  Here are the first couple of paragraphs:

"A growing number of hospitals are finding their relationships with physicians strained. Despite the fundamental importance of this relationship, a surprising number of these institutions are paralyzed by the challenge of building productive and sustainable relationships with physicians. The task, they often lament, is simply too complex."

"Unfortunately, doing nothing is not likely to be effective. In the absence of action, frustration and distrust will multiply on both sides, further undermining any possibility of useful collaboration. Doing something is a better alternative." 

Click here to read Beckham's list of suggestions.

See One, Do One, Write One

I was reading one of Graham's older posts at Over My Med Body!  - See One, Say One, Teach One from May 2004.  Graham, a medical student was sharing an important insight he had as he suddenly realized the power he wielded as a physician baring bad, life-changing tidings to a patient.  Graham had a BFO (Blinding Flash of the Obvious) and he wrote about it in his blog. 

One of the most powerful learning tools I've ever experienced was a monthly assignment I had during my two years of graduate school.  Each month, my assignment was to write a five page reflective essay applying what I was learning in graduate school to what I was doing in real life.

During the second year, we were required to share our essays with the entire cohort and were then required to make written comments on at least two classmates' papers. In addition to learning to coherently articulate my thoughts, I learned to write constructive commentary and to accept and value feedback, which furthered my learning even more. 

These papers were not about learning to write like an English major (I can feel some of you shuddering across the Internet at the idea of writing anything more in depth than an op note.)  They taught me to think about what I was reading, studying and hearing in lectures, to apply it to what I was doing in real life and to express my thoughts in a way that others could understand.

I'm glad some med students are blogging.  It's a fabulous form of self-reflection.  But what I would really love to see is reflective writing integrated into a medical school curriculum.  It would be a powerful way for students to capture their emotions and experiences before they get lost forever in the mountains of information and reams of data that must be assimilated during medical training. 

In my opinion, we'd be taking a major step toward graduating emotionally intelligent doctors who, having gone through the exercise of tying their thoughts, feelings and experiences to what they had learned, would be more in touch with themselves and their patients.  What's not to like about that?

Peak Performers & the Vertical Learning Curve

One of the hallmarks of peak performers is that they are acelerated learners.  They reframe what others might label as mistakes or failures as "learning opportunities".  They are constantly and voraciously learning. 

Most of us arrive in medical school because we ARE peak performers.  Being a peak performer is the price of entry. But something seems to happen between the end of school/training and mid life.  I'm not sure whether we get tired of learning or we just get so busy that its easier to fall back on what we already know, or perhaps there's so much learning to do to keep up with advances in clinical medicine that we sometimes feel maxed out and just give up.

Regardless of the reason, as an industry, we are now paying a heavy price - specifically in our unwillingness to learn to use technology.  And until we buck up and embrace technology, we will continue to pay. 

The American College of Physician Executives (ACPE) did a survey last year on physicians and technology.  Read the article entitled Survey Reveals Physicians' Love Hate Relationship with Technology by David O. Weber from The Physician Executive, March-April 2004 pp. 4-10.  The results are enlightening and I highly recommend it.

There's an excellent article in the latest edition (March-April 2005 p.40) of The Physician Executive entitled Professionalism in Medicine:  The New Authority by Dr. Anthony Oliva.  This article, published exactly one year after the article above points out how physicians are losing ground as a result of our slow adoption of technology.

Oliva starts off by describing how the medical profession struggled to create and confer professsional authority over a period of many years.  But now our authority is being quickly eroded by forces in the marketplace like consumerism, performance information (now dissimenated electronically in the form of "best doctor lists") and marketing by pharmaceutical companies and other entities.

Oliva stresses the importance of physicians taking a leadership role in securing our professional authority for the next generation of healthcare practitioners rather than allowing the marketplace to usurp it.

Barriers to our success (roughly paraphrased from the article) are:

1. We have failed to set our own standards (allowing the marketplace to set them for us).
2. We lack the technology infrastructure to document and evaluate performance.
3. We do not have the systems in place to hold ourselves accountable.
4. We have not even begun to allow for the transparency needed to create the cultural shift.

We must, as a profession embrace technology - but even more basic still, I think we should be looking deeper for what might potentially be an even greater problem.  Even though our young physicians are graduating with great savvy in technology, will there just be some other disruptive phenomenon that comes along when these physicians are in mid-life?  Will they be as resistant to change as we physicians in mid-life are now?

Because acelerated learning is so critical to the success of peak performers, if physicians are to thrive as peak performers now and in the future, perhaps we should be teaching young physicians not just how to use technology (which in my mind is just content), rather we should be teaching them how to learn.

The Forest for the TRIZ

I just finished taking a class on TRIZ (Russian acronym for Theoria Resheneyva Isobretatelskehuh Zadach).  TRIZ (pronounced TREES) is a robust creative problem solving methodology developed by Genrich Altshuller in the 1950s. 

This process has been used extensively in many industries for innovative problem solving, new product/service development, creating and improving systems, capturing cost savings, boosting productivity and developing breakthrough technology.  It has not- surprise, surprise, been used to any great extent in healthcare.  I think it has tremendous potential and I'm looking for an opportunity to apply some of the concepts I've learned. 

Two quotes our instructor shared on the last day of class are the following:

“The worst sin of all is to do an excellent job at that which should not have been done at all”   --NY Times, anonymous

“We never have time to do it right, but we always have time (and money!) to do it over.”    -- Anonymous.

When I saw these quotes, I immediately thought of healthcare.  The first and most critical step of TRIZ is to define the problem.  If you don't take the time to get that part right, you'll be forever doing it over or worse still, working on the wrong thing altogether! 

I think we're continually doing things over in healthcare either working on the wrong problems or creating the same problems, making the same mistakes because we haven't taken the time to properly identify and define the problems in the first place.   Society is definitely paying the price. 

Altshuller developed the TRIZ methodology after he studied thousands and thousands of patents and discovered that there are really only a limited number of prinicples (about 40) involved in all of them.  According the Altshuller there is already an answer to every problem in existence, all one has to do is take existing knowledge and apply it differently.  The TRIZ methodology is a systematic way to innovate new solutions based on priniciples that have already been thought through.

I was attending a course at the American College of Physician Executives a couple of years ago.  I asked another participant attending a different course whether he was getting anything out of it.  He said, "Well, it would be a lot better if they would stop wasting our time giving us case studies on non-healthcare companies." 

When will we get it?  What is it about us docs that we feel compelled to continually reinvent the wheel (or just stick with the same old wheel we've been using) despite the fact that the wheels we develop aren't working anyway?  TRIZ is just one of the excellent methodologies that have been proven to be effective in other industries.  Anyone interested in learning more?

 

Special Status

Physicians often fall into the trap of developing a false sense of self-importance.  There are lots of aspects of practicing medicine that contribute to the development of this state of mind.  For example, when I'm called in for an emergency, everything and everyone around me is instantly put on the back burner until that emergency is resolved.  Everyone has to wait until I'm finished.

People call me "doctor" and for the most part give me a certain level of respect not always afforded to others.  Patients arrange their own schedules around their doctors appointments rather than vice versa. 

As a result of all of these factors, many of us develop a sense of having "special status."  We sometimes even come to believe that we care more about our patients than anyone else.

Once I've internalized the belief that I have special status I am more likely to discount the contributions made by others.

I had a physician client who asked me to help him with some morale problems he was having with the office staff.  I had the staff fill out a survey, then I interviewed each staff member about what it was like to work in the office for this physician. I was impressed with the sincerity and competence of the staff, their dedication and loyalty.

Each of them told me that their boss was a wonderful doctor, but that he was not very approachable and he seemed kind of cold to them.  They did not feel appreciated. 

When I reported back to the physician on his staff's perception of him, he was surprised.  He said, "Giving excellent patient care is so important to me that I focus so intently on taking care of my patients I just don't have time to pay that much attention to my staff."

I asked him if he thought they did a good job and he said that he did. Then I pointed out to him that each member of his staff was just as focused on providing the very best patient care as he was and in their various roles, they each gave outstanding patient care.  Each of his staff members was a critical part of the team in his office - an office which had a reputation in the community for giving excellent patient care.

He stopped for a moment then admitted that he had never really thought of his staff in that way.  Some time later I checked back in with the staff and learned that the physician had become much more open with them, making a point of thanking them for their work, complimenting them and taking more interest in them.  Morale was up and things were much better.

Albert Einstein once said, "A hundred times every day I remind myself that my inner and outer life depends on the labors of other men, living and dead, and that I must exert myself in order to give in the measure as I have received and am still receiving."

I think this quote is a good reminder that even though I AM a doctor, so what?  I'm no better or worse than anyone else.  I have no special status in the world.  To the degree that I remember to be grateful for all the things others have done and are doing for me - from inventing electricity to answering my phone and keeping my schedule straight, I am more open and approachable - more human - for in fact, that's all that any of us are.