In Lincoln Hospital case study - third party intervention:

Survey techniques and devices utilized during the human process intervention :

1?Surveys - if a formal survey used it should be included here in the proposal as a appendix

Lincoln Hospital: Third-Party Intervention soon after the election of a new chief of director; indeed, he had campaigned on a surgery, the president of Lincoln Hospital promise to get her fired. faced a crisis. Lincoln, a 400-bed for-profit Lincoln's president was faced with a difficult hospital in the southwestern United States, was experiencing severe problems in its oper- choice. On the one hand, he needed to satisfy ating room (OR). Forty percent of the OR the physicians, who during the tenure of his nurses had quit during the previous eight predecessor had become accustomed to getting months. Their replacements were significantly their way in personnel matters by threatening less experienced, especially in the specialty to take their patients elsewhere. The market areas. Furthermore, not all could be replaced; was, as the physicians knew, increasingly when the crisis came to a head, the OR was competitive, and the hospital was also faced with escalating costs, changes in government short seven surgical nurses. regulations, and strict Joint Commission on Also, needed equipment often was not Accreditation of Hospitals standards. Could the available. On several occasions, orthopedic president afford to alienate the surgeons by surgeons had already begun surgery before opposing their newly chosen representative- they realized the necessary prosthesis (for who had a large practice of his own? example, an artificial hip, finger joint, or knee On the other hand, could he afford to sacrifice joint) was not ready, or was the wrong size, Mary? She had been OR director for 13 years, or had not even been ordered. Surgery then and he was generally satisfied with her. As he had to be delayed while equipment was bor- later explained, rowed from a neighboring hospital. Other serious problems also plagued the OR. For Mary is a tough lady, and she can be hard to get along with at times. She also doesn't example, scheduling problems made life smile all that much. But she does a lot of extremely difficult for everyone involved. things right. She consistently stays within Anesthesiologists often were unavailable her budget .... when they were needed, and habitually tardy Furthermore, whereas Don had long been an surgeons delayed everyone scheduled after outspoken critic of the hospital and was gen- them. The nursing shortage exacerbated these erally distrusted by its administrators, Mary difficulties by requiring impossibly tight was loyal, a strict constructionist who adhered scheduling; even when the doctors were firmly to hospital policies and procedures: ready to begin, the scheduled nurses might still be occupied in one of the other operating She is supportive of me, of the hospital, and rooms. of our interests. She doesn't let the doctors get away with much. She has been an almost The surgeons were at odds among themselves. faultless employee for years, in the sense Over 30 of them were widely regarded as that she comes to work, gets the job done, prima donnas who considered their own time never complains, and doesn't make any more valuable than anyone else's and would waves. I really don't understand the reason even create emergencies in order to get "prime for the recent problems. I trust her and want time" OR slots-for which, as often as not, to keep her. It would be extremely difficult to replace her. In Hospital copy 2 they were late. Worst of all, however, the doctors and nurs nurses were virtually at war. The last point was a key one; a sister hospital Specifically, Don, the new chief of surgery, had spent almost three years unsuccessfully as at war with Mary, the veteran OR trying to recruit an OR director.After talking with both nurses and doctors, rain. ... All we want is to provide quality the president decided not to fire Mary. Instead, patient care, and she refuses to let us do that, he told both Mary and Don that they must She doesn't follow through on things. resolve their differences. They were to begin He particularly resented Mary's lack of And just as Don's assessment echoed, in an but she was a good one. Her conservative, meeting right away and keep on meeting, deference. exaggerated form, the doctors' perception of tenacious, no-nonsense style had earned the however long it took, until they got the OR Mary's behavior is so disgraceful it is almost Mary as an exceptionally strong-willed woman, trust of administrators and the respect of OR straightened out. laughable. She shows no respect whatsoever Mary's assessment of Don echoed his reputa- nurses, as well as some physicians. As one The results were predictable. Neither party for the physicians. ... She thinks she can tell tion among the orthopedic nurses and hospital nurse asserted: "Good OR managers are hard administrators, who feared and distrusted his to find and certainly Lincoln is far better off wanted to meet with the other. Mary thought us what to do and order us around; and I am quick temper and sharp tongue: not going to put up with it any longer. When with Mary than without her." the whole exercise was pointless, and Don saw it as a power struggle that he could not afford I agreed to take this job as chief of surgery. Not only that, but I find his filthy mouth very I promised my colleagues that I would clean offensive. I am not going to cooperate with The doctors, in general, supported Don, to lose. The president, who wanted an observer him when he behaves like that. Nobody else though some of them had reservations. At one extreme, an anesthesiologist began with a present, chose Terry, the new executive vice up the mess that has plagued the OR for years. I have a mandate from them to do talks to me that way and gets away with it. Nobody, I won't put up with it. As long as he classic disclaimer: president and chief operating officer. Mary whatever is necessary to accomplish that. didn't know Terry very well so she asked that behaves that way, it is a waste of time to Now, I want you to know that I don't have The docs are sick and tired of being abused, meet with him. I am sure that I am doing any problems with Mary, personally. In fact, her boss, the vice president of patient services, and I am going to deal with this lady head things that bother him, and I want the OR to I really like her. We have been friends for sit in. Don, who "didn't trust either Mary or on. If we got rid of her, 95 percent of our run as smoothly as possible. But there is no years, and we get along just great. her boss as far as he could throw them," problems would go away. She has just gone way we can deal with these problems unless countered with a request for a second of his too far this time. we can sit down and talk about them with- Nevertheless, he was convinced the OR out being abusive. problems were "100 percent Mary's fault. I own, the vice president for medical services. In his cooler moments, Don admitted that have no doubt about that." Furthermore, When the meeting finally occurred, it quickly Mary was only partly to blame for the OR'S Clearly, both Mary and Don had strong needs although he claimed to be, as an anesthesiolo degenerated into a free-for-all, as Don and problems, but he still insisted she must be fired, to control other people's behavior, while gist, "a completely neutral third party in this Mary exchanged accusations, hotly defended if only to prove to the doctors that the hospital remaining free of control themselves. It is sig- whole business," he clearly shared Don's nificant that each used the word abuse to themselves, and interpreted any interventions administration was concerned about those assumption that Mary's job as an OR manager describe the other's behavior. They did respect by the three "observers" as "taking sides." problems, and that something was being done. was to keep the surgeons happy: each other's technical abilities, but morally. Mary saw Don as "an egotistical jerk, " and he Her people hate her. She is a lousy manager. saw her as a "rigid, petty tyrant." Neither She just can't work with the MDs. Surgeons DIAGNOSIS are a rare breed, and there is no changing Observation: I am always a bit suspicious trusted the other, thus, each was inclined to them. You have got to get someone in there At this point, Lincoln's president called me. We about the objectivity of someone who has misconstrue even unintentionally negative who can work with them and give them negotiated a psychological contract, where the reached the conclusion that someone must comments-an especially disastrous state of what they want. president shared the above historical informa- be fired. There is almost always something affairs in the gossipy environment at Lincoln, else that is going on that requires more where surgeons, nurses, and administrators His conclusion echoed Don's: "She ought to tion, described the problem as he saw it, and were quick to relay, and amplify, the signals of be fired, if for no other reason than to prove identified his expectations of me and for the investigation. project. I, in turn, articulated my expectations of hostility. that something is being done to address the problems in the OR." the president. We then agreed to take no steps Mary was both angry and bewildered. She It was obvious from these initial interviews until I had interviewed both Don and Mary. saw herself as fair and consistent in dealing that Don and Mary were largely contributing to the OR problems; but it was also obvious Later that afternoon, Don expressed his anger with doctors and nurses: that many others had a stake in the outcome Observation: I am always leery of someone and frustration with the hospital administra- who says, "It is all her fault." When Things had gone relatively well until six of their battle. I therefore went on to inter- someone is blamed for 100 percent of the tion and, most of all, with Mary: months ago. At that time, some of the ortho- view the surgical head nurses, the vice presi problem, it usually evidences either denial I don't want to have anything to do with this pods started scheduling surgeries and then dents for patient services and medical services, or a coverup. There may be a completely lady. She is a lousy manager. Her people canceling them at the last minute, which, in the executive vice president, the president, innocent party in an emotionally charged turn, fouled up the schedule for the rest of the and 25 physicians. conflict, but I have never met one. can't stand to work with her. We don't have the equipment or the supplies that we need. doctors. When I called them on it, Don went on a rampage. He is the leader of the pack. The vice presidents and the surgical head Emotionally charged conflicts are always power struggles, and it takes two parties The turnover in the OR is outrageous. The nurses agreed with the president: Mary might and now he has blood in his eyes. is eyes . I have tried to play that game. best nurses have quit, and their replacements don't know enough to come in out of the to talk with him about it, but he won't listen. not be the hospital's most personable manager,INTERVENTION I do that bugs her. Somehow, criticism is only at this point did actual third-party always easier to take when it is accompanied A less enthusiastic partisan, a surgeon who The high turnover among OR nurses was a facilitation intervention begin. I used a design by something positive. was a 10-year veteran of the Lincoln OR, was particularly sore point among the surgeons in general, whose frustration was explained that included perception sharing, problem It also helped that before making any accusa- very conscious of the way expectations such identification, contracting, and follow-up tions against each other, they were required as those expressed by Don and the anesthesi- by Don: meetings. At their first formal meeting together to examine their own behavior. As Mary ologist were apt to be viewed by others in the I don't think the administration has a clue as to how urgent this matter really is. It takes at with me and the three vice presidents who acknowledged, neither had ever taken the medical community: least five years for a surgical nurse to gain the acted as observers, Mary and Don began by time to figure out specifically how he or she Quite frankly, I am embarrassed to admit that necessary skills to be useful. In the last two writing answers to three questions: might be causing problems for the other: I am a surgeon in this town; by doing so, I am months, we have lost some of the best nurses automatically branded as an egotistical dim- I have ever worked with in my life. As a 1. What does he or she do well? It had never really occurred to me that I may wit. With only a few exceptions, those guys result, I had to start the training process all 2. What do I think I do that bugs him or her? be doing something that caused Don to react are a group of conceited, narcissistic techni- over again. It has seemed like I've been 3. What does he or she do that bugs me? that way. Vaguely, I suspected that I may be cians who are so caught up with themselves doing something that he didn't like, but I was that they have no clue about what is going working with a group of student nurses! This turnover has cut my productivity by more The very process of writing things down was hard pressed to identify what it was. I really on around them. Some of them are bullies, helpful. It gave them time to get used to this had to stand back and say to myself, "What is and they push the rest of us around because than 50 percent. it that I am doing that is making this working we don't have the patient census they do. Most of the doctors blamed the high turnover explicitly confrontational situation before either of them had a chance to "pop off" at the relationship go sour?" I had spent so much His assessment of blame was correspondingly on the nursing managers' inability to retain time concentrating on what he was doing that more moderate than the anesthesiologist's: qualified personnel, whereas the managers other, and it forced an element of rationality into an emotionally charged situation. Also, bugged me that I hadn't looked at myself. "A lot of people would like you to think that blamed it on the doctors' verbal abuse. And in fact, a significant number of doctors were the questions required specific answers conc- The oral discussion of this question made it this problem is one sided, and that Mary is widely regarded by some of their peers as well erning behaviors, not subjective generalizations obvious that neither was intentionally causing totally responsible for this mess. But that isn't true." And while he supported Don, whom he as by the nurses as impatient, intolerant per- about personalities. Listing specific behaviors problems for the other, making both parties made each of them realize that at least some of less hypersensitive to imaginary insults. Also, described as reasonable and willing to listen to fectionists who demanded far more of others the things they disliked about the other could because both were much harder on them- logic, his principal wish was to avoid personal than they did of themselves. involvement: "I am glad he is fighting this From the extended interviews, it was obvious be changed. selves than they were on each other, the battle. I won't. The thought of getting caught that while Mary had greater credibility with They then explained these responses orally, in milder criticisms they did subsequently direct between him and Mary scares me to death." the hospital administration and Don had the order shown in Exhibit 1. Because of their at each other were not nearly as offensive as This last wish was vividly elaborated by more backing from the doctors, each had a mutual hostility, I thought it safer to require they would otherwise have been. another surgeon, who also highlighted the certain amount of power over the other's that at first they address their remarks only to The next step was to identify specific problems general perception of Mary as a strong constituency: Mary controlled the surgeons' the third party, not to each other. Each, how- for Mary and Don to address. They wrote personality: working conditions, while Don controlled a ever, was required to hear the other's presen- their responses to question three on a sheet of significant portion of the hospital's patient tation so each would understand the other's newsprint, assigning vectors to represent the I don't mess with Mary at all. I'm not stupid. It's true that I don't like some of the things flow. The OR problems could not be resolved perceptions. And because both were guaran- relative seriousness of the problem. Some of that she does. Sometimes she is just plain without genuine cooperation from both of teed an uninterrupted speech, each was more the most serious problems could be resolved ornery. But I also am not willing to take her them-especially from Don, who was outside likely to listen to the other. Taking up the immediately; others were going to take lon- on. In fact, at this point, I will do whatever the formal hierarchy of the hospital and could positive perceptions first helped. As Don later ger, but at least Don and Mary now knew she wants, whenever she wants it. If the not be coerced by the president. explained: what their priorities had to be. other docs are smart, they won't mess with her either. They can talk big in their meet- I met again privately with each of them to I was stunned to hear her say those positive ings, but if they have any sense, they won't determine whether they were honestly com- Finally, it became possible for them to agree on hings, particularly the part about me taking mitted to improving their working relation- specific behavioral changes that might help. mess with that lady. She controls too many care of her family. For a long time, I had seen Don and Mary each defined what they wanted of the resources I need to do my job. So far ship. Both were skeptical about the possibility her as my enemy, and I expected only the of real change but said they were willing to do worst. I was amazed that she had so much from the other and negotiated what they them- she has been very helpful, and she has gone out of her way to do me some favors. I don't everything they could to help, as long as their respect for me. As a result, many of my nega- selves were willing to undertake; I moderated want to mess that up. I think it is great that own basic values were not violated. Each tive feelings for her began to leave. It is really the meeting and wrote down the decisions. Don is willing to take her on, and I wish him defined the kind of help he or she was willing tough to stay angry at someone who says so (At the end of the meeting, Don, Mary, and success. That way, if she wins, it will be him to accept from me and the circumstances many nice things about you. I also found that the three observers each received a copy of that gets beat up, not me. under which that help was to be given. I was much more willing to listen to what these commitments.) Because Mary and Donwere interdependent, either could easily have sabotaged the other's efforts. Therefore, in defining each action item, I reminded them to specify responsibilities for both parties: . what will Don (Mary) do to resolve this problem? 0 What will Mary (Don) do to help the other succeed? This technique made both parties jointly responsible for resolving each problem and thus changedthe wholedynamicoftherelationship from mutual isolation to collaboration, from denial of responsibility to acceptance of respOn- sibility, and from a focus on problems to a focus on solutions. During the next year. I had four more meetings with Don, Mary, and the three vice presidents. Before each meeting, I intervieWed each par- ticipant privately. At the beginning of each meeting, the participants gave general reports on what was going on, between Mary and Don and in the OR in general. In particular. Iasked the two to list positive events and specific behaviors on each other's part that thel' appreciated. They then reviewed the commitments they had made during the pre- vious meeting. In almost every case, both Mary and Don had kept these commitments, thus building a basis of trust for further com- mitments during the latter part of the meeting. Where they had not kept the commitments, plans were made to ensure follow-through before the next meeting. Questions 1. If you had been called by Lincoln's presi- dent to help resolve the problems described in the case, how would you have carried out the contracting and diagnosis stages? What would you have done differently than what the 0D consultant did? Is third-party intervention an appropriate intervention in this case? Other possible OD interventions? How effective was the intervention? Next steps? third-party SOURCE: R. Wayne Boss. University of Colorado; Leslee S. Boss. Organization Research and Development Associates,- Mark W. Dundon. Sisters of Providence Hospital