The role of leaders to mitigate conflict and protect patients

In 2009, The Joint Commission came out with a new leadership standard LD.02.04.01 (“The hospital manages conflict between leadership groups to protect the quality and safety of care”). This standard mandates the early identification and resolution of conflict in healthcare organizations. In addition, effective March 31, 2011, the new MS.01.01.01 standard mandates that the organized medical staff develop a process to manage conflict between the medical staff and the medical executive committee. These conflicts include but are not limited to proposals to adopt a rule, regulation, policy, or an amendment thereto (EP 10). Why is conflict such an accreditation concern and what is its role in potentially undermining patient safety?

Many of you will recall the tragedy involving the Continental Express commuter plane that occurred near Buffalo, NY last year. Many thought that the plane crashed because of ice on the wings or poor visibility. In truth, the black box that was recovered determined that instead of focusing on the landing as required under the FAA “sterile cockpit” rules, the pilots were in a heated discussion about their poor working conditions and pay. During this discussion, warning lights indicated that the plane was flying dangerously slow and was at risk of losing loft. Instead of lowering the nose of the aircraft to increase its airspeed, the pilot raised the nose causing the plane to “stall out.” Subsequently, 50 lives were lost. 

Similarly, when a physician and nurse are involved in a long-term dispute or the medical staff is in conflict with senior management or the board, the focus becomes the conflict and not the patient. During my first consulting engagement, I was asked to help resolve a conflict between the medical staff and a surgeon who would not report to the hospital while on call due to untreated depression. The medical staff didn’t want to confront the surgeon, and management and the board looked the other way. In addition,  the nurse on duty didn’t want to rock the boat or risk losing her job by going up her chain of command. As a result, two patients in their 40s died from normal post-operative complications. The physician nearly lost his professional career, and the hospital nearly lost its local reputation and trust. Just as this case demonstrates, poor communication and conflict are at the root of most sentinel events.

The following are effective conflict resolution vehicles to identify and manage conflict before potentially tragic consequences ensue:

1. A joint conference committee made up of the medical executive committee (MEC) and the board committee to resolve disputes between the MEC and governing board when the interests of the medical staff and hospital are in conflict.
2. A medical staff conflict resolution committee is an opportunity for the organized medical staff and the MEC to resolve differences over bylaws, rules, regulations, and policies as required under the new MS.01.01.01 standard.
3. A physician council addresses potential conflicts between non-hospital-based physicians, medical staff leadership, and senior management.
4. A physician-nursing council addresses potential conflicts between the medical staff and the nursing department.
5. Physician-nursing dyads address potential conflicts between physicians and nurses within a clinical department.
6. Internal or external conflict resolution resources to engage in mediation, non-binding, or binding arbitration.

Whatever the venue, the key is to address potential conflict at its earliest stage and to mitigate or ideally resolve it so that it does not become a distraction to the effective and safe treatment of patients.

Many organizations have moved beyond regular conflict resolution mechanisms and have engaged in crew resource management (CRM) training. CRM permits the care of patients through well organized multi-disciplinary teams. One of the key techniques in effective team communication is to raise concerns in a non-judgmental environment as early as possible and to use that opportunity to brainstorm possible implications of the concern. This is an opportunity to prevent similar issues from occurring in the future. CRM represents the next evolution in conflict resolution and is part of a larger framework of communication tools (e.g., SBAR, effective hand-offs, etc.) to create seamless communication.

Medical staffs should work with their organizations to address sources of potential conflict and to use effective conflict resolution mechanisms to minimize its affect on patient care.

Hopefully, events such as the the Continental Express crash and the tragic loss of two patient lives following low-risk surgery will be things of the past as we move forward in a more collaborative and mutually supportive way.

Wishing you continued success.

Jon Burroughs, MD, MBA, FACPE, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.