So, what's the problem? - Conflict Management

Physician Executive, July-August, 1999 by John Ludden

AT HARVARD MEDICAL

School in Boston, one gray building bears an inscription, in Latin and in concrete: Ars Longa, Vita Brevis,"1 Roughly that means that the "art" of medicine takes a long time to master, and lifetimes are short. That was true when Hippocrates chiseled out the phrase and since then the "art" has gotten longah. And even if life expectancy has doubled, it is still too brief Imagine these pieces of a day's agenda for a busy physician executive:

1. Morning- Management Committee. Update on Status of Clinical Information System

2. Afternoon- Vendor Selection Committee: Selection of Disease Management Company for Diabetes

3. Evening- Physician Compensation Committee: Restructuring Financial Incentives for Staff Physicians

Behind each of these colorless labels, there is a story to be told and some 'problem to solve. Each of the Issues has a history that we are more or less aware of It could even be that each of the issues is related to the others.

Medical care presents complex problems to physician executives-thoughtful problem definition is a critical management task. Without understanding the context, cultures, bottom line implications, and personal relevance, problem definition is incomplete and problem resolution may be inadequate or inappropriate. Physicians and other executives often push to action before a problem is understood. At other times, the nature of an issue is intuitively grasped and unnecessary formal analysis may delay vital intervention.

1. join the Management Committee discussion

As the meeting unfolds, we're reminded that the clinical information system has been under development in a partnership with an outside vendor. Originally we specified that the system have operational capabilities (among others) to link hospital lab and radiology data to outpatient clinical offices and, on an annual basis, to supply data for several HEDIS measurements that are required by the HMOs that we contract with.

Today, we hear first that the vendor cannot deliver both elements on the original timeline without a major increase in our resources. Without much warning, there are difficult choices to make. Before the opening presenter finishes speaking, we are thinking: Can we change vendors at this point? Did we change the scope of work after the contract was signed? If we did, why? Failing to deliver HEDIS results to our HMO contractors will mean that we didn't meet part of our contract and either financial penalties, a poor showing on their report card" to our patients, or a decrease in their business with us. Or all three. We know also that failing to deliver daily lab and radiology data to the outpatient practices will mean that we don't meet our commitment to supply data to those practices so that they can manage their subcapitation more effectively. They will want to renegotiate the deal, So, what's the problem?

Do we understand the problem?

If our choices are complex, some of the difficulty may lie in our understanding of the problem. First we listen to the story told by the vendor and the in-house managers. They're saying that our original specifications were incomplete and caused an underestimation of resources. Further, they tell us that the HEDIS specifications delivered by our HMOs have changed five times in the last eight months and that their complexity and scope has morphed from a simple reporting of claims-based findings about immunization to requiring a continuous scan of several pharmacy databases as well. We hear that our laboratory is now contracting to do the basic lab work for the outpatient practices, that their volume has tripled, and that the systems developers have seriously underestimated the complexity of reporting data to multiple practices that have differing technological competence. None of this is a new tune.

We also "listen" to the financial implications of our predicament. We hear what it might cost to bring the project in on its original timeline and what it might cost to lose HMO business. We hear the potential lost savings that may occur in the outpatient practices if we delay the delivery of lab and radiology data.

Do we understand the problem? What we really understand is the situation. If all we "fix" is the situation, the problem will reappear in a short time. Part of the story will come out if we listen to our reactions to the situation. Suppose that the physician executive quickly feels that this is just what he expected from this project, as in "I knew this would happen!" Or, suppose that the executive committee starts to play the "blame game," going around the table citing the failures of contingency planning by the contracting staff, or the changing of specifications on the part of the medical staff. "But we all agreed to this contract, didn't we?"

Step back

If we step back and ask, "What is the problem, anyway?" we might be able to construct a better response. Stepping back enables us to ask whether, in light of our organization and its direction and limitations, this "problem" makes sense to us. Until it makes sense, we can't say we've grasped the problem well enough to plan any action. In other words, until we have properly defined the problem, we can't act to resolve it.