Gaining hospital administrators' attention: Ways to improve physician–hospital management dialogue

Original communications

Gaining hospital administrators’attention: Ways to improve physician–hospital management dialogueKenneth H. Cohn, MD, MBA, FACS,a Sandra L. Gill, PhD,b and Richard W. Schwartz, MD, MBA,FACS,c Cambridge, Mass, Lisle, Ill, and Lexington, Ky

Background. Despite marked differences in training and professional interests, physicians and hospitalmanagers face similar problems stemming from the unprecedented rate of change in the health caredelivery system: failure of reimbursement to keep pace with rising costs, new therapeutic modalities,increasing government and managed care regulations, heightened consumerism, and an aging patientpopulation. In the face of these mounting challenges, both physicians and hospital managers couldbenefit significantly from a climate of collaboration and interdependence.Methods. This article presents a ‘‘case report’’ of a community teaching hospital in which practicingphysicians and hospital administrators collaborated to develop an operating plan for the next 3 years toimprove the practice environment.Results. The physicians recommended new clinical priorities to enhance service to patients and families,to improve physician-physician communication, to develop clinical protocols, and to build coordinateddiagnostic treatment centers, which the administration has implemented.Significance. Physicians and hospital managers can no longer pass on cost increases at will to patientsand third-party payers. Nor can physicians and managers ignore the heightened power of patients andthird-party payers. Effective dialogue and collaboration are in all parties’ interests to optimize patientcare and to develop innovative services. Despite the tensions created by competition and rapid change,transformation from a blaming to a learning environment may be a key strategic advantage in today’shealth care marketplace. (Surgery 2005;137:132-40.)

From the Cambridge Management Group,a Mass; the Benedictine University, b Lisle, Ill; the Division ofGeneral Surgery, Chandler Medical Center,c University of Kentucky, Lexington

IRONICALLY, THE FORCES that are pushing physiciansand hospital managers apart may be what ulti-mately reunite them. Both groups are experienc-ing unprecedented change and uncertainty. SinceSeptember 11, 2001, uncertainties associated withbioterrorism threats, recession, and war havediverted attention and resources away from healthcare reform. In addition, medical malpractice costshave continued to escalate, adding billions ofdollars to health care costs.1 Information technol-ogy, new medical devices, and patented pharma-

Accepted for publication September 10, 2004.

Reprint requests: Kenneth H. Cohn, MD, Cambridge Manage-ment Group, 625 Mount Auburn Ave, Cambridge, MA 02138.E-mail: [email protected].

0039-6060/$ - see front matter

� 2005 Elsevier Inc. All rights reserved.

doi:10.1016/j.surg.2004.09.006

132 SURGERY

ceuticals have created pressures for increasedspending in the absence of a proven return oninvestment. The pressure to individualize therapyis outpacing society’s ability to afford new ad-vances.2 Consumerism and information technologybring increasing transparency to processes thatoperated previously without public scrutiny;3 bothpatients and employers are unwilling to be passiveconduits for annual price increases. An agingpopulation for whom Medicare reimbursementgenerally fails to cover the rising costs of care,massive state budget deficits, and the increasingburden of uninsured patients create a wideningchasm between health care expectations andresources.4

Financially solvent hospitals are necessary toensure that the spectrum of community healthcare needs is met. Profitable hospital services,such as cardiology, neurosurgery, and orthopedicsurgery, traditionally subsidize unprofitable but

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SurgeryVolume 137, Number 2

Cohn, Gill, and Schwartz 133

medically necessary services, such as pediatricsand mental health.5 Attesting to the urgency forphysician–hospital management collaboration isthe rapid growth of independent ambulatorycenters competing for lucrative procedures. Toimprove the practice environment for physiciansand patients and to keep hospitals financiallysolvent so that they can continue to serve thepublic good, physicians and hospital managementmust learn to work interdependently.

Tension is created by the competing needsfor excellence in an individual competitive market-place and the need for shared organizational goalsthat transcend individual differences.6 Attempts tonegotiate shared governance by physicians andhospital management in the past have been unsat-isfying and resulted in self-fulfilling prophecies ofdistrust and alienation.7 At a minimum, effectiveresolution of these tensions necessitates that phy-sician leaders master organizational skills (eg,communication, negotiation, conflict resolution).8

The purpose of this article is to exemplify ways,using a case study, to improve physician–hospitalmanagement dialogue, resolve conflicts, and fostermeaningful collaboration.

RATIONALE

Patriot Hospital (a pseudonym for a communityteaching hospital in the northeastern UnitedStates) is a 350-bed community teaching hospitalaffiliated with a tertiary academic hospital, whichhad gross revenues of $200 million and an oper-ating loss of $20 million.9 Although the size of theoperating loss was troubling, many physicianslacked a sense of accountability for the hospital’ssuccess and survival and viewed financial losses onitems such as expensive prostheses as the hospital’sproblem. Furthermore, immediate operationalcrises, such as a nursing shortage and capacityproblems in the operating and emergency rooms,made discussions of long-term planning a lowpriority.

Department chairs, community physicians, andhospital managers expressed skepticism aboutany approach to change. However, a memberof Patriot’s senior management team who onceworked at another hospital where a structureddialogue process was successful recommendedfurther discussions with physicians and manage-ment.

After several months of discussion, the hospitaland medical staff committed to a structureddialogue process because both the hospital andthe practicing physicians felt that the physiciansneeded a voice in determining clinical priorities

over the next 3 years. The hospital CEO and VicePresident of Medical Affairs led the process ofconvening a Medical Advisory Panel (MAP) byselecting 2 physician co-chairs based on theirclinical ability and on the respect that they enjoyedwith their peers. One of the co-chairs was ahospital-salaried trauma surgeon and intensive careunit director; the other was a gastroenterologist inprivate practice. The co-chairs in turn selected 11other panel members based on clinical ability,leadership skills, and peer credibility. The co-chairsprincipally were able to persuade clinical col-leagues to serve on the MAP because the hospitalCEO reassured them that he would do everythingin his power to implement the MAP’s recommen-dations. He told them that he had tried otherroutes to deal with current problems, includinga hiring freeze and budget cuts, and that heneeded to get the physicians on board.

Patriot’s MAP was intentionally separate fromthe hospital’s Medical Executive Committee. Al-though there was some overlap in membership ofthe two entities, the MAP membership was broaderand more representative of Patriot’s medical staff.Furthermore, the hospital needed the MedicalExecutive Committee to focus on credentialingand quality monitoring activities. The complemen-tary nature of the roles of the Medical ExecutiveCommittee and the MAP became more apparentover time, particularly after the MAP had writtenits report and shared it with members of theMedical Executive Committee, as discussed below.

THE STRUCTURED DIALOGUE PROCESS

To develop its recommendations, the MAPsolicited input from the medical staff at largethrough a series of meetings and presentationswith each clinical department and section. MAPmembers picked physician presenters from eachclinical area to obtain consensus from their col-leagues regarding future clinical priorities. TheMAP asked each clinical area to write a report thatoutlined its goals, long-term strategy, and short-term tactics. A week after completing the writtenreport, the physician presenter appeared beforethe MAP to summarize recommendations andclarify questions.

To support the clinical areas in developing theirpresentations, the hospital provided staff andfinancial and demographic data, as requested.Each section and department received inpatientdata regarding market share, and profit and lossstatements for the previous 3 years, from whichthey could obtain additional data from the hospi-tal’s cost accounting system.

SurgeryFebruary 2005

134 Cohn, Gill, and Schwartz

The MAP met weekly for 4 months to hear thepresentations from all major clinical departmentsand sections. The first presentation occurred ap-proximately 1 month after the MAP convened,allowing time for MAP members and presenters toobtain necessary background information abouthospital operations, nursing, marketing, finance,information services, and managed care contracting.

This timeframe also gave the presenters sufficienttime to meet with their colleagues and to write theirreports. During this time, physicians received onsitecoaching in management principles, which facili-tated their learning business principles withoutrequiring them to attend special courses.

The vice presidents for medical affairs, patientcare services, and managed care contracting wereinvited to listen to the sessions and to developfamiliarity with the process and the panelists. Theirattendance helped to build familiarity betweenphysicians and management, facilitated face-to-face communication, and paved the way for theimplementation process, as discussed below.

Attending the meetings also benefited manage-ment since it gave them a chance to hear froma panel of clinical leaders and not merely squeakywheels, as had occurred in the past. Throughsection-wide discussions, written reports, and oralpresentations, the MAP enlisted the clinical exper-tise of Patriot’s medical staff, whose opinions couldnot be disregarded easily.

Everyone involved agreed that the processoffered community physicians the opportunity toinfluence the hospital’s clinical direction. Clearly,many physicians were skeptical of this process inthe beginning. However, encouraging skepticalphysicians to voice their opinions allowed themto become part of the process and to feel that theywere keeping the process focused on improvingcare for the community.

Grading written and oral section reports accord-ing to their potential to improve care, enhancecommunication, and increase market share allowedthe MAP to weigh priorities. To establish a frame-work for evaluating the presenters’ recommenda-tions, the MAP agreed that the physician communityand the hospital would embrace 4 themes:

d Improve service to patients and families.

d Enhance physician-to-physician communication and

simplify the physician consultation process.d Implement protocols in all major diagnostic-related

groups to save money, limit variation, and improve

quality and safety.d Develop coordinated diagnostic and treatment centers

in cancer and cardiovascular diseases.

The MAP incorporated these themes into a writ-ten report, which they presented to the medicalexecutive officers and staff, to senior managementand department chairs, and finally to the board oftrustees, who endorsed the recommendationsunanimously. To outsiders, this positive receptionmay be surprising because the 4 Patriot themesmight be considered mundane. For Patriot,however, obtaining consensus on these issues wasa major achievement because its physicians hadnot embraced these themes previously.

Once the MAP concluded its initial report, thehospital worked to implement the MAP’s recom-mendations:

d The CEO and his senior administrative team met

weekly to review and improve service to patients and

families, resolving to change their competitive strategy

from that of a high-tech hospital with the latest devices

to a technologically advanced community hospital that

emphasized service. Patient representatives were ex-

pected to make daily rounds and be proactive rather

than reactive in improving service. Frontline employ-

ees were taught the Disney principles of ‘‘Listen,

Apologize, Solve the problem, and Thank patients

for their input’’ as a way to improve their service.d The medical staff agreed to meet quarterly to discuss

new developments, programs, and services; they felt

that face-to-face contact improved physician–physician

communication far more than sending out newsletters

that few people made time to read; consulting

physicians also agreed to fax their evaluations to

requesting physicians within 24 hours rather than

making physicians wait for a mailed letter.d Physicians developed protocols that provided im-

proved results quickly (eg, a protocol for heparinized

patients that decreased telephone pages from the

nurses and improved outcomes, and a postanesthetic

care unit extubation protocol that cut overnight stays

by one third) and then built on those successes to

develop consensus in more controversial areas, such as

computerized physician order entry.d A coordinated diagnostic and treatment center for

patients with gastrointestinal complaints is under

construction.

The MAP reconvened quarterly to monitor thestatus of implementation; several of the physiciansfrom the MAP chose to be involved in implement-ing the initiatives. As a result, there is a renewedemphasis on patient satisfaction, and surgicalvolumes and market share have increased, espe-cially in minimally invasive cardiac surgery. Theimprovement in volume and market share hasresulted from new programs and services as wellas from increased volume from specialists who



Table I. Some cultural differences between physicians and hospital management

Cultural variable Physicians Management

Sources of income Consultations and procedures Largely salary, small variablecomponent

Focus Patient survival Organizational survivalDecision-making Rapid, based on individual judgment/

experience, patient centeredDeliberate, based on consensus,

patient and resource centeredCustomary time horizon Hours-days Weeks-monthsResponsive to Patients, families, colleagues Patients, families, physicians,

employees, communityorganizations, board of trustees

previously split their admissions among competinghospitals. The hospital became profitable over thefollowing 2 years, although it would be incorrectto attribute profitability solely to a structureddialogue process. The budget deficit triggeredmany operating reforms as well. However, bothPatriot management and physicians felt that thestructured dialogue process guided by the MAPaccomplished the following:

d Improved the way that physicians related to their

colleagues and served their community.

d Put leadership for clinical direction back in the hands

of physicians.d Provided an innovative approach to strategic and

operational planning based on physician guidance.d Ensured an effective learning experience for physi-

cians using project-based, just-in-time learning, which

gives physicians the background information they

need to understand issues at the interface of medicine

and business as part of a clinically based project. For

example, physicians were taught about direct costs

(costs involved in providing a given service, such as

laboratory tests) and indirect costs (costs incurred

regardless of the volume of services provided, such as

heat and electricity) just before they saw the profit and

loss statements for their departments; they found this

focused approach analogous to reading an article on

a patient problem because it allowed them to retain

the knowledge more effectively than taking courses or

reading a textbook.d Provided an excellent approach for grooming the 13

physician leaders who served on the MAP by broad-

ening their focus beyond their specialties.

DISCUSSION

Brief history of the physician--hospital manage-ment relationship. The mid-1960s to mid-1990smarked a golden age for physician autonomy andcontrol. The advent of Medicare meant that

physicians and hospitals were paid for deliveringcare that they had previously rendered withoutcharge. Federal funds became available to supportand expand residency training.10 Although pre-dictability and stability characterized US healthcare,11 these conditions did little to unite physi-cians and hospital managers. Fee-for-service re-imbursement created incentives to pass on costsrather than to collaborate and economize. Differ-ences in education, training, and priorities rein-forced the communication gap between physiciansand hospital managers.6 In general, practicingphysicians tend to employ a fast-paced decision-making style centered on individual patients; incontrast, hospital managers tend to employ a slow-er, consensus-based decision-making style focusedon their organizations (Table I).8 In short, withminor exceptions for paid medical staff, privatephysicians lose money when they attend hospitalmeetings and do not see patients.

As market-based forces strengthened, physi-cians’ and hospital management’s power to setprices and exert control over patient care dimin-ished. The 1997 Balanced Budget Act led todecreased Medicare reimbursement for hospitals.Medicare’s sustainable growth restrictions andarbitrary regional variations have had a similardownward effect on physician reimbursement.12

Uncertainty over future income at a time whencosts are rising has created a poor climate forphysician–hospital management collaboration.13

The increasing number of regulations and rigorof enforcement have created yet another strain onthe physician--hospital relationship.14 Under boththe Emergency Management Treatment and ActiveLabor Act (EMTALA) and the Health InsurancePortability and Accountability Act (HIPAA), hospi-tals are expected to be the enforcers of rulesrelated to emergency coverage and privacy.

A further strain on physician--hospital manage-ment relations arises from the proliferation



Table II. Strategies for dealing with conflict

Strategy Characterization Potential uses Potential disadvantages

Avoidance Lose–lose Not worth the effort Conflict not resolvedNot one’s problem to solveAdditional information neededPossible improvement with time

Fighting Win–lose Urgent action necessary (eg, safety, ethical,or legal issues)

Resentment and apathy

Surrender Lose–win Other party correct, not worth the effort Conflict not resolvedLittle chance to gain, or chance to gain on

more important issue in futureCompromise Partial win–lose Incompatible demands, stalled

negotiationsSuboptimal decisions

Time pressures, temporary fix necessaryCollaboration Win–win Interest in reaching creative solution(s) to

important issues and building positivelong-term relationships

Time/effort

of physician investor--owned niche hospitals andambulatory diagnostic/treatment centers that com-pete effectively for profitable patients (eg, patientswith cardiovascular, orthopedic, and neurosurgicalconditions). The number of these centers has growngreater than 45% in the last 6 years.15 From theperspective of hospital management, competitivefacilities draw insured patients away from hospitalsand increase hospital procedural costs becauseoverhead must be divided among a smaller pool ofpatients. If present trends continue, ambulatorydiagnostic and treatment centers could make hos-pitals the dumping ground for high-cost patientswith multiple comorbid conditions and, thus, ne-cessitate curtailing the provision of unprofitableservices that have been an integral part of themission of community hospitals.5

We do not suggest that solving communicationdifferences will erase physicians’ current irritationover increased workload and decreased reimburse-ment. Yet, divisive attitudes, stemming from theaforementioned issues, lead to insular thinkingthat is counterproductive to process improvement.For example, physicians typically view globalhospital shortages in nursing, pharmacy, andtechnologist staffing as signs of administrativeincompetence, ignoring their own responsibilityfor creating a nonthreatening work environmentconducive to the recruitment and retention ofhigh-quality personnel.16 Billiar17 wrote that physi-cians have grown inwardly focused in response tothe complexity and unpredictability of their dailylives. Physicians need a better sense of theircollective priorities; without improved physician–physician communication, improved physician–

management communication is unlikely. As dis-cussed in the case study, lack of unity amongphysicians will preclude the ability of managementto pursue a course that has collective physicianendorsement.7

The need for change: Physicians and hospitalmanagers need a system with greater predictabilityso that they can function at a higher level ofefficiency, productivity, and quality. Unpredictabil-ity leads to wasted time, duplication of services,increased expenses, and declines in revenue. Forexample, Lewis18 estimated that $470 billion isspent annually on US health care administrativeexpenses, far exceeding the estimated $190 billionrequired for caring for the entire uninsuredpopulation. Morrison and Smith19 dubbed thecurrent system as ‘‘hamster health care,’’ in whichcaregivers have to run faster and faster just to standstill. Inefficiency at every level makes all partiesfrustrated and is hardly the optimal condition forestablishing a spirit of trust and collaboration.

At the local level, improved physician--manage-ment interaction may not immediately improvepricing power, but it might result in enhancedefficiency and, thus, an improved competitiveposition. Perhaps the greatest long-term value ofimproving physician--management communica-tion lies in developing shared perspectives thatenhance mutual respect and build trust. Becausephysicians collectively influence hospital revenue,clinical costs, quality, and safety issues, the practiceof having physicians involved in a meaningful wayin setting hospital priorities may provide a compet-itive advantage.7 As Anthony and Govindarajan20

advocate, creating a ‘‘learning’’ (as opposed to



a ‘‘blaming’’) environment is the only sustainablecompetitive advantage.

Requirements for success of the structured dialogueprocess: The willingness of physicians and manage-ment to work interdependently and the desire toovercome the pain of the status quo are moreimportant than the type or size of the hospital. Theultimate success of a structured dialogue processdepends on several factors, including the leader-ship of the co-chairs of the MAP, the quality ofdiscussion that the physician presenters and MAPfoster, the physicians’ shared sense of accountabil-ity for implementing the MAP’s recommendations,and management’s willingness to listen to andimplement the MAP’s recommendations. To sup-port these goals, physicians and management mustagree on the following principles at the beginningof the structured dialogue process:

d The first priority is the community, followed by the

patients whom the physicians serve, the physicians

themselves, and, finally, the hospital.d The personal integrity and professional standing of

the physicians selected to chair the process and to be

members of the MAP must be so great that the list of

names tells colleagues that something of lasting

significance is about to happen.d The hospital executives, staff, physician presenters,

and the MAP play it straight. Hospital executives

actively assist the physicians, as requested, realizing

that the dialogue and recommendations may not fit

the current hospital model. The CEO and hospital

board of directors have to commit to following the

MAP’s recommendations for the physicians to commit

the time as presenters and panelists. Maximizing CEO

and board buy-in is more than a leap of faith; it is in

everyone’s interest for this collaborative effort to

succeed, especially the community, which manage-

ment and physicians are committed to serve. Similarly,

the physicians recognize their interdependency and

responsibility for each other and the hospital; they

scrupulously maintain confidentiality during and after

presentations to the MAP so that MAP members can

think out loud without concern that their remarks will

be leaked and so that hospital management can be

assured that the financial data they release to physi-

cians will not be leaked to competing centers.

d The dialogue and recommendations are comprehen-

sive. Just as physicians realize that they have an

opportunity to affect decisions for clinical resource

investment for the hospital, they also understand that

their recommendations address the needs of the

entire medical community. Long-standing feuds, petty

jealousies, and the wish to avoid the process are

obstacles that must be overcome. The recommenda-

tions are by and for the physicians; no minority reports

are accepted.

d The process is part of an ongoing, long-term plan for

physicians to engage in their own professional and

economic affairs as well as in the decision-making and

leadership of the hospital. The physicians must de-

velop detailed descriptions of where they want to be as

a community of providers now and over the following

3 years. Physicians are reluctant to participate unless

they know in advance how progress will be measured.

A multidimensional set of outcomes and measures

needs to be developed to track results and to manage

performance.

The reasons for individual physicians to join thisprocess are varied. For some, the primary motiva-tion is to improve care for the community and toleave a legacy; others clearly feel the pain ofdiminishing reimbursement and increasing ex-penses for which working harder is not a sustain-able solution. Enlisting physicians in a process ofstructured dialogue is a long-term strategy thatbegins with building trust and credibility, andculminates after 4 to 6 months with improvedfocus and clarity about future goals and withheightened ability of physicians to communicateboth with one another and with management.Although the weekly meetings consume a consider-able amount of professional time, the resultsdecrease feelings of disenfranchisement, and in-crease feelings of ownership and participation inimproved health care for the community. MAPmeetings with management and officers of the

Table III. Database to facilitate physician–management communication

Name of practitionerYears of serviceDepartmentSectionAnnual discharges (last 3 years, trend)Annual revenues (last 3 years, trend)Annual profit (last 3 years, trend)Information needs of practitioner from hospital/

frequencyPreferred mode of contact (in person, telephone,

electronic)/frequencyInformation needs of hospital from practitioner (away

dates, recruitment plans, succession plans, patientoutcomes)

Issues practitioner would like to solve/urgency/ hospitalcontact/proposed solution/roadblocks, progress

Issues hospital would like to solve/urgency/officecontact/proposed solution/roadblocks, progress



Medical Executive Committee monthly or quar-terly after the evaluation and report-writing phasehelp maintain momentum for implementing rec-ommendations, and provide a forum for obtainingphysician input for controversial issues in thefuture.

Additional tools for improving physician--hospital management collaboration. Dialogue andappreciative inquiry: Effective dialogue is in bothparties’ self-interest to acknowledge gaps in trustand work to bridge them. Dialogue requires a spiritof inquiry, suspension of judgment, identificationof assumptions, silence and reflection, and activelistening for participants to understand how thedifferent perspectives fit into a larger picture ofshared meaning.21

Inquiry is an open process designed to fosterthe exchange of ideas, generate multiple alterna-tives, and produce well-tested solutions.22 Effectiveleaders pay careful attention to the way they frameissues, conveying openness to new ideas andmaking clear that initial opinions are provisionalas more information becomes available. Advocacy,which involves tests of strength among competingpositions (a common physician communicationstyle), leads to a win–lose mentality that suppressesinnovation, and fosters compromise and avoidancerather than collaboration (Table II).23

Appreciative inquiry (AI) is a tool that focuseson learning from success instead of uncoveringdeficits, problems, and individual or collectiveweaknesses.24 AI involves discovering the bestaspects of a team or organization, understandingthe dynamics that foster superior performance,and celebrating, reinforcing, and building on pastsuccess. Appreciative inquiry is based on thefollowing 3 principles:

1. People within organizations respond to positive

knowledge, which reinforces self-esteem.

2. Both the shared vision of the future and the process

for developing the shared vision create the energy to

drive lasting change.

3. The power of affirmation and envisioning of goals

increases the likelihood of transforming goals into

reality.24

Storytelling and recording are an integral partof appreciative inquiry because stories flesh outmetaphors, decrease the inhibiting effects ofhierarchy, and provide vignettes that are remem-bered more readily than facts.25 Shared imageryand energy to improve is generated by approach-ing the data in a fresh way, as if through the eyes ofa child, writing the stories in the first person in thequoted language of the person who told them and

sharing the stories with the rest of the organiza-tion.26

As Jaffe27 noted, administrators and physiciansneed to develop mutual trust and respect; blamemust be eliminated from the vocabulary. Trust ina working environment can occur on 2 differentlevels. Transactional trust improves individual rela-tionships by allowing people to clarify expectationsand resolve conflicts. Transformational trust buildsmomentum that can generate energy betweengroups and catalyze systemic change, thus exertinga far-reaching effect on the organization.28

Conflict resolution: Conflict involves real or per-ceived differences between people who believethat their feelings, thoughts, or actions are in-compatible.23,26 Conflict can also arise from poorcommunication or from personalizing organiza-tional issues.29 In reality, conflict alerts people todifferences and therefore is neither positive nornegative. The response to conflict determines thevalues ascribed to conflicting situations (TableII).30

Collaborative conflict is characterized by anapproach in which people attack challenges ratherthan one another, thereby solving problems ina way that satisfies both parties and builds positive,long-term relationships. The success of the collab-orative approach depends on the parties’ prepara-tion, in which they analyze what each wants toaccomplish, what each is willing to concede, whateach party’s goals might be, what assumptionsneed to be clarified, what ‘‘hot buttons’’ mightcause an angry response, and what special precau-tions should be taken.31

The setting for the discussion is important.Being seated at right angles or next to each otheris preferable to sitting across from each other,which invites opposition. Outlining the issues andfocusing on broad principles on which agreementis likely are useful approaches to providing a foun-dation on which both parties can build trust andcredibility. Asking exactly what the other partywants helps to clarify assumptions. Listening ac-tively, paying attention to the other party’s bodylanguage and tone of voice, suspending judgment,using empathy to summarize and clarify data, andavoiding inflammatory words such as ‘‘but, why,you, never, always’’ help to move the parties towardbrainstorming multiple options and, eventually,agreement. Introductory phrases, such as ‘‘I wouldappreciate your help solving ..,’’ foster team-based rather than adversarial relationships. AsKennedy29 stated, ‘‘Tact can be taught—once it’sseen as an organizational necessity rather thana social skill.’’



Validating content and feelings with, ‘‘If I un-derstand you correctly..’’ clarifies issues and letsthe other party know that what he or she is saying isimportant. Focusing discussions on the presentand future rather than on the past, seeking ways toenlarge the pie (as opposed to dividing a shrinkingpie), and allowing the other party to come awaywith something by which to save face are alsohelpful tactics.31

In summary, collaboration is a win--win ap-proach to resolving conflict that encourages clearpreparation and definition of issues, establishes anenvironment conducive to open, honest commu-nication, focuses on issues rather than assigningblame for the past, allows the parties to ownsolutions rather than to feel that a solution wasimposed upon them, and celebrates successes andthe building of trust.23 Conflict is effectively re-solved when people feel acknowledged, respected,informed, and involved.32

How physicians and hospital leaders can fostercollaboration: The initial manner in which physiciansand hospital leaders can foster collaboration is tomake the opening of communication channels andthe building of trust a high priority by using face-to-face communication initially, rather than relying onmemos or electronic mail, unless an individualactually prefers to receive electronic mail. Physi-cians and hospital leaders need to share informa-tion in a customized manner by understanding whateach group needs from the other, at what time, andhow frequently. An important role for the senioradministrative team is to develop a customizeddatabase for practitioners that contains his or herinformation needs, preferred communication me-dium (ie, voice, electronic, printed), desired fre-quency of communication, issues that need to beaddressed, administrative responsibility, and prog-ress toward meeting goals. We suggest building thisdatabase in an iterative fashion, beginning with thehighest volume and revenue-producing physicians,regardless of their irascibility. A sample databaseformat appears in Table III.

To decrease conflict arising from inadequatecommunication and from personalizing differen-ces in perception, busy physicians and hospitalmanagers must make time to work proactively andcome to know one another in noncrisis settings,finding common perspectives inside and outsidethe hospital environment. A number of venues canbe successful, including breakfast discussions, in-formal chats between elective procedures whileawaiting room turnover, hospital administratorsvisiting physicians’ offices, physicians and admin-istrators traveling together to attend conferences/

workshops, or visiting a community facility to-gether with board members. The important con-sideration is that discussions start in the present,rather than waiting until an unspecified, ideal timein the future.

Any large, seemingly impossible task needs to bebroken down into small, measurable steps withmutually agreed-upon timelines and joint celebra-tions of accomplishments at regular intervals. Inaddition, sharing risk and reward can help to alignincentives between physicians and the hospital,acknowledging that complete alignment is un-likely. Physicians and hospital leaders need effec-tive dialogue to decide where they will partner andwhere they will compete.

CONCLUSION

Clearly, physicians and hospital managers dis-play different perspectives and behaviors stem-ming from their training and professionalinterests. Rapid changes in the clinical and finan-cial health care environment and the need toconsider the interests of many diverse constituentsmake conflict inevitable. Although challenging,a process of constructive dialogue and conflictresolution can yield innovative ideas, efficiencies,new and improved services, enhanced revenue,better outcomes, and an improved work climatefor both physicians and hospital leaders.

The authors are grateful to Ms Judith Hower forresearch and editorial assistance.

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Documents

Gaining hospital administrators' attention: Ways to improve physician–hospital management dialogue