1 Ares Leung 2012 Alignment Guide to conflict resolution 2 Ares Leung: Professional Profile 100- doctors under several teams, mostly specialists 100- doctors under several teams, mostly specialists Union Hospital Union Hospital Governance, Innovation, Clinical Departments Governance, Innovation, Clinical Departments O&G Specialty O&G Specialty Service to College, Pioneer in gynae endoscopy Service to College, Pioneer in gynae endoscopy Teaching & training capacities Teaching & training capacities Supervisor to Complaint Handling arm Supervisor to Complaint Handling arm Group for 18 years Group for 18 years Specialty for 10 years Specialty for 10 years Whole Hospital (300 beds) for 7 years Whole Hospital (300 beds) for 7 years Content 2. Alignment Model: The Concept of Conflict Resolution 2.1 Preparation 2.1 Preparation 2.2 Effort during Alignment Process 2.2 Effort during Alignment Process 2.3 Post - Alignment 2.3 Post - Alignment 3 1. Background: Complaint Analysis 4 Incidence of formal complaints Complaints to doctors Complaints to doctors Complaints to all ranks in all outlets: 2.5 times Complaints to all ranks in all outlets: 2.5 times Most frequent with some staff profiles Most frequent with some staff profiles New to an institute / environment / practice mode New to an institute / environment / practice mode Vulnerability related to communication skill Vulnerability related to communication skill Not necessarily those technically lagging or inter-professionally unwelcome co-workers Not necessarily those technically lagging or inter-professionally unwelcome co-workers Source: Union Hospital, HK 2010 5 Contributions to medical conflicts Many claims (70%) - poor communication Many claims (70%) - poor communication Patients feel badly treated in communication Patients feel badly treated in communication misunderstanding from professional, inadequate information given, misunderstanding from professional, inadequate information given, feeling of devaluation or being deserted feeling of devaluation or being deserted Surgical Claims Surgical Claims 1 / 4 poor explanation 1 / 4 poor explanation 1 / 8 surgical mishap 1 / 8 surgical mishap The rest: mismatched expectations The rest: mismatched expectations Source: International literature 6 Root causes to medical conflicts Medical Errors Medical Errors Only 1-3% of litigations arise Only 1-3% of litigations arise 2/3 of litigations arise without medical error 2/3 of litigations arise without medical error System Responsibility current mainstream concept System Responsibility current mainstream concept Useful with root cause dissection Useful with root cause dissection Non-blame culture Non-blame culture Extensively adopted in Aviation Industry Extensively adopted in Aviation Industry Element of personal accountability Element of personal accountability still worthy of consideration still worthy of consideration 7 Intention behind litigations Explanation and/or apology Explanation and/or apology Accountability of people and organizations Accountability of people and organizations Address to deficiency in standards Address to deficiency in standards Compensation for expenses (10 to 20%) Compensation for expenses (10 to 20%) (a possible element for complaints although not litigations: clients attending an institution could be psychologically prepared to complain if outcomes do not match expectations) (a possible element for complaints although not litigations: clients attending an institution could be psychologically prepared to complain if outcomes do not match expectations) 8 Reasons to communicate when things go sour Usually no negligence involved Usually no negligence involved Adversity unavoidable sometimes (at least ) Adversity unavoidable sometimes (at least ) Unfavorable outcome is one of several certain outcomes Unfavorable outcome is one of several certain outcomes High risk clients undergoing high risk & complicated management procedures in high risk places (variable experience in teammates) High risk clients undergoing high risk & complicated management procedures in high risk places (variable experience in teammates) Good patient interactions, care coordination, effective communication after unfavorable outcome reduce chance of patient action against doctors. Good patient interactions, care coordination, effective communication after unfavorable outcome reduce chance of patient action against doctors. Error not disclosed: patients more likely to take formal/legal advice/action. Error not disclosed: patients more likely to take formal/legal advice/action. Content 1. Background : Complaint Analysis 2.1 Preparation 2.1 Preparation 2.2 Effort during Alignment Process 2.2 Effort during Alignment Process 2.3 Post Alignment 2.3 Post Alignment 9 2. Alignment Model: The Concept of Conflict Resolution 10 What is Alignment? Alignment of thinking Alignment of thinking Between 2 parties Between 2 parties key to agreement key to agreement Automatic at start of regular consultation Automatic at start of regular consultation Solution for a health concern Solution for a health concern Directions angulated if not directly opposite during complaints Directions angulated if not directly opposite during complaints Relationship rebuilt if interests re-aligned Relationship rebuilt if interests re-aligned Key to success: seek similarity (+/- preserve difference) Key to success: seek similarity (+/- preserve difference) Applicable to all conflicts Applicable to all conflicts Clients, amongst peers, across ranks, between institutes.. Clients, amongst peers, across ranks, between institutes.. 11 Rationale behind Alignment Find a point with similarity Find a point with similarity Preserve difference Preserve difference Shift views to agreement for common goals Shift views to agreement for common goals Both parties work for new goals Both parties work for new goals Preparation History/ Internal Review Parties to consider Feelings to adopt History/ Internal Review Parties to consider Feelings to adopt Alignment Process Post- Alignment Alignment Model Your Approach Setting Your Approach Setting Obtain Health Info Identify your target Seek Similarities Align with Empathy Apology for bad feelings Assessment of alignment outcome Self Reflection: Psychology of self Maintenance of doctor-client relationship Assessment of alignment outcome Self Reflection: Psychology of self Maintenance of doctor-client relationship Content 1. Background: Complaint Analysis 2. Alignment Model: the Concept of Conflict Resolution 2.2 Effort during Alignment Process 2.2 Effort during Alignment Process 2.3 Post - Alignment 2.3 Post - Alignment Preparation Preparation History/ Internal Review Parties to consider Feelings to adopt History/ Internal Review Parties to consider Feelings to adopt Alignment Model Your Approach Setting Your Approach Setting Internal review onto cause and effect of incident; involved personnel, circumstances Inter-professional communication: thorough fact finding Preparation of coherent answers Internal review onto cause and effect of incident; involved personnel, circumstances Inter-professional communication: thorough fact finding Preparation of coherent answers Two elements in everything Physical / bodily course Psychological aspect Parties to consider Patient Family and other stakeholders Ourselves Two elements in everything Physical / bodily course Psychological aspect Parties to consider Patient Family and other stakeholders Ourselves Feelings to adopt Empathy Sympathy Feelings to adopt Empathy Sympathy Preparation History/ Internal Review Parties to consider Feelings to adopt History/ Internal Review Parties to consider Feelings to adopt Alignment Model Your Approach Setting Your Approach Setting Team Approach: +/- most senior leader Timely: early, not over-hurry, adequate time for explanation Adequate notice to family members Speak on behalf of others / institute only upon understanding & authorization Team Approach: +/- most senior leader Timely: early, not over-hurry, adequate time for explanation Adequate notice to family members Speak on behalf of others / institute only upon understanding & authorization Location: privacy, safety to staffs, adequate spacing to accommodate reasonable number of relatives Professional company & Witness Location: privacy, safety to staffs, adequate spacing to accommodate reasonable number of relatives Professional company & Witness Content 1. Background: Complaint Analysis 2. Alignment Model: the Concept of Conflict Resolution 2.1 Preparation 2.1 Preparation 2.3 Post - Alignment 2.3 Post - Alignment Effort during Alignment Process Alignment Process Alignment Model Obtain Health Info Identify your target Seek Similarities Align with Empathy Apology for bad feelings Something both parties have in similarity Common concern for an issue: usually health Therefore start with seeking information about health development Alignment Model Obtain Health Info Identify your target Seek Similarities Apology for bad feelings Direct towards a commonly accepted solution course of treatment & the outcome Alignment Process Align with Empathy Alignment Model Obtain Health Info Identify your target Seek Similarities Apology for bad feelings Throughout course of events : seek common lines Move foci so that both parties agree with new principles and solutions Both parties move, not just one side. Principles remain unchanged Some original standpoints may be fixed at start/ intermediacy Throughout course of events : seek common lines Move foci so that both parties agree with new principles and solutions Both parties move, not just one side. Principles remain unchanged Some original standpoints may be fixed at start/ intermediacy Alignment Process Align with Empathy 20 When things go wrong Communication with patient Communication with patient Accurate information Accurate information Unknown facts: register, find out, do not guess Unknown facts: register, find out, do not guess Sincere Sincere Early and decisive in timing Early and decisive in timing Fail-safe clinical care not cascade of accidents Fail-safe clinical care not cascade of accidents Clinical notes Clinical notes Accurate and complete Accurate and complete Never change, may supplement Never change, may supplement Record of discussion after adverse event, witness(es) Record of discussion after adverse event, witness(es) 21 Psychological Responses of doctors and patients after adverse outcome Professionals: Professionals: Loss grief reaction Loss grief reaction Fight & flight Fight & flight Patients: Patients: Needy for psychological care & welfare Needy for psychological care & welfare Absent access to professional-technical information Absent access to professional-technical information Trust on doctor used to assess creditability of explanation Trust on doctor used to assess creditability of explanation mutually interactive mutually interactive Interpret fight/flight as doctors lack of concern, evidence of poor care; independent of error existence Interpret fight/flight as doctors lack of concern, evidence of poor care; independent of error existence 22 Practical Advice for Attitude in Alignment Empathy + Empathy is the capacity to recognize and, to some extent, share feelings (such as sadness or happiness) that are being experienced by another sentient or semi- sentient being. Someone may need to have a certain amount of empathy before they are able to feel compassion. (Wikipedia 2011 ) [Sympathy is] social affinity in which one person stands with another person, closely understanding (anothers) feelings (Wikipedia 2011) Sympathy Considerably overlap in definitions with empathy Usual connotation Sympathy comes from ones own perspective Empathy means feeling in the other person Sympathy Alignment Model Obtain Health Info Identify your target Seek Similarities Apology for bad feelings Alignment Process Align with Empathy Empathy is felt by a recipient when doctor l istens with attention, and summarizes client physical + psychological experience 24 Handling of complaining patients Active Listening: Active Listening: A need of patients A need of patients Less strict necessity without disagreement: professionals having upper hands Less strict necessity without disagreement: professionals having upper hands Their story heard and acknowledged Their story heard and acknowledged One cannot disagree with listener One cannot disagree with listener Discussion Discussion Truthful Truthful Information till satisfaction Information till satisfaction Indication of Regret / Sorrow Indication of Regret / Sorrow Future Prevention (if possible) Future Prevention (if possible) Agreed plan for care Agreed plan for care Alignment Process Alignment Model Obtain Health Info Identify your target Seek Similarities Align with Empathy Apology for bad feelings Sorry seems to be the hardest word? Admission of liability? Fear inside Professionals 26 Impact on reputation Impact on reputation How to speak to the patient How to speak to the patient Acknowledging probable mistake from ourselves Acknowledging probable mistake from ourselves How much did we contribute to the incident How much did we contribute to the incident Patient being emotional Patient being emotional Patient antagonistic action to us Patient antagonistic action to us Difficulty in handling our own emotions Difficulty in handling our own emotions 27 Sorry seems to be the hardest word Admission of Liability? Sorry originates usually from sympathy. Sorry originates usually from sympathy. 'Sorry' to express feelings about experience, or emotions of another person, does not admit liability 'Sorry' to express feelings about experience, or emotions of another person, does not admit liability I am sorry that it hurts. I am sorry that it hurts. I am so sorry that you are experiencing this terrible pain as a result of this wound infection. I am so sorry that you are experiencing this terrible pain as a result of this wound infection. Apologising for attendants actions / behaviour may indicate admission of liability Apologising for attendants actions / behaviour may indicate admission of liability I am sorry that I stepped on your foot. I am sorry that I stepped on your foot. I regret you were given a wrong dose of your medication. I regret you were given a wrong dose of your medication. There is additional room for refinement There is additional room for refinement Erroneous admission of liability: court decides in relation to whole event Erroneous admission of liability: court decides in relation to whole event 28 When we say sorry Accurate documentation, down to exact words Accurate documentation, down to exact words Choices exist Choices exist Tell our own feelings: I / staffs involved / staffs of the Hospital are all very unhappy / concerned about you, unhappy about what happened Tell our own feelings: I / staffs involved / staffs of the Hospital are all very unhappy / concerned about you, unhappy about what happened Acknowledge directly clients suffering, loss and anger Acknowledge directly clients suffering, loss and anger Express our care and understanding to patient distress Express our care and understanding to patient distress Mention possible different management but only when necessary Mention possible different management but only when necessary Restrict use with Restrict use with Our Hospital expresses regret about (Organizational feelings ) believable? Our Hospital expresses regret about (Organizational feelings ) believable? Express as Regret? (note Chinese translation) Express as Regret? (note Chinese translation) Content 1. Background: Complaint Analysis 2. Alignment Model: the Concept of Conflict Resolution 2.1 Preparation 2.1 Preparation 2.2 Effort during Alignment Process 2.2 Effort during Alignment Process Post - Alignment Post- Alignment Alignment Model Assessment of alignment outcome Self reflection: Psychology of self Maintenance of doctor-client relationship Assessment of alignment outcome Self reflection: Psychology of self Maintenance of doctor-client relationship Reporting MPS (local/overseas, HKMA, law firm) The unit / institute Standard regulator / licensing body Initiate investigation if necessary; Analysis for lessons, Report back to stakeholders New facts Remedy Possible recipients - patient / family on new findings & facts Attention to worker emotional needs Doctor & co-workers Post- Alignment Alignment Model Assessment of alignment outcome Self reflection: Psychology of self Maintenance of doctor-client relationship Assessment of alignment outcome Self reflection: Psychology of self Maintenance of doctor-client relationship Emotion of Professionals Grief (loss) + embarrassment Unhappy, shame & fear, isolation Escape Mechanisms: Denial, Discount, Distancing Psychosomatic: fall in concentration, insomnia Loss of confidence and image Apparent cascade of unlucky events after one incident could be related to confidence and change in modes Natural Reaction: Psychological Defences Re-interpret incident & re-define mistake Negate the error, suppress memory Accuse circumstances, disease, co-worker, patient Avoid reminders/discussions/patient Emotion of Professionals Grief (loss) + embarrassment Unhappy, shame & fear, isolation Escape Mechanisms: Denial, Discount, Distancing Psychosomatic: fall in concentration, insomnia Loss of confidence and image Apparent cascade of unlucky events after one incident could be related to confidence and change in modes Natural Reaction: Psychological Defences Re-interpret incident & re-define mistake Negate the error, suppress memory Accuse circumstances, disease, co-worker, patient Avoid reminders/discussions/patient 32 Psychological Welfare of Professionals Healthy professional - healing hands for clients Healthy professional - healing hands for clients Professionals also suffer multi-dimensional Professionals also suffer multi-dimensional Summary: grief reaction (major loss) plus embarrassment Summary: grief reaction (major loss) plus embarrassment Bad outcome: burnt-out, resort to substance abuse Bad outcome: burnt-out, resort to substance abuse Anxiety about professional reputation Anxiety about professional reputation Amongst patients / coworkers Amongst patients / coworkers Reluctance to seek support Reluctance to seek support professional pride, submission to helped role, familiarity to support attendants professional pride, submission to helped role, familiarity to support attendants Feeling alone in a crowd Feeling alone in a crowd 33 Psychological Support to Professionals Professionals take care of others, who to take care of them? Professionals take care of others, who to take care of them? Help and advice are available from some sources: Help and advice are available from some sources: employer organization employer organization their own healthcare attendant: psychologist, counselor, doctor their own healthcare attendant: psychologist, counselor, doctor (professional and specialty organizations still underdeveloped in HK) (professional and specialty organizations still underdeveloped in HK) Post- Alignment Alignment Model Assessment of alignment outcome Self reflection: Psychology of self Maintenance of doctor-client relationship Assessment of alignment outcome Self reflection: Psychology of self Maintenance of doctor-client relationship Additional Material Support to Clients - New dimension & consideration International experience suggests management of patient expenses may decrease subsequent patient action against a doctor and cost of claims Seek advice from indemnity providers (at least friend) during consideration to waiving or reducing fees following an adverse outcome; and also with statements potentially interpretable as admission to liability; These acts are always associated with verbal (preferably witnessed) statement as gesture of goodwill Forced Alignment Conventional art & soft alignment sometimes does not produce consensus. Conventional art & soft alignment sometimes does not produce consensus. One or more levels up One or more levels up To seek the similarity within To seek the similarity within To produce forced consensus To produce forced consensus Effect may not be negative Effect may not be negative Work place conflict between workers: up one level to supervisor Work place conflict between workers: up one level to supervisor Client conflict failing resolution: up to society (law court) Client conflict failing resolution: up to society (law court) Yardstick could be appropriate society benchmarks Yardstick could be appropriate society benchmarks New consensus may bring in New consensus may bring in New perspectives about similarity New perspectives about similarity Human mind influenced by actions Human mind influenced by actions True understanding and consensus True understanding and consensus 35 Preparation History/ Internal Review Parties to consider Feelings to adopt History/ Internal Review Parties to consider Feelings to adopt Alignment Process Post- Alignment Alignment Model Your Approach Setting Your Approach Setting Obtain Health Info Identify your target Seek Similarities Align with Empathy Apology for bad feelings Assessment of alignment outcome Self Reflection: Psychology of self Maintenance of doctor-client relationship Assessment of alignment outcome Self Reflection: Psychology of self Maintenance of doctor-client relationship 37 Successful alignment helps to win patients trust Quality of interpersonal relationship before & after the event with outcome inferior to expectation Perceived caring Perceived competence 38 Ares Leung Serving Union Hospital Prestige Medical Centre Paragon Clinic HKCOG & others 2011