Special Report:Administrator/Clinician Clashes …...crucial conversation with the nurse (or the nurse’s man-ager) about his competence concerns with her allowed the problems to

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Clearly the nurse could have communicated morecompletely so the doctor could have made a better deci-sion. Defined protocols for communication can help inthis regard as well.

The doctor could have been more solicitous andprobing to ensure complete understanding. But there wasa deeper issue at play. One that is all too common inhospitals. And one that causes mistakes, undermines doc-tors’ effectiveness, burns out staff and raises costs.

The deeper issue was the doctor’s failure to addresshis long-standing concern with the nurse’s competence.He had long believed she showed poor judgment andhad little trust in her assessments and recommendations.

Furthermore, he felt he was the victim of her incom-petence, as she would frequently awaken him in the mid-dle of the night for trivial questions that a well-trainednurse should be able to handle.

How did this play into the nighttime disaster? In sub-tle, but very direct ways. The doctor’s failure to hold acrucial conversation with the nurse (or the nurse’s man-ager) about his competence concerns with her allowedthe problems to persist. And the persistence of theseproblems irritated the doctor.

In a sense, since he failed to talk out the problem,he instead acted out the problem, through brusque com-ments, officious treatment towards her, and a tendency tominimize her concerns. This behavior caused her to oper-ate less effectively than before. She procrastinated com-municating with the doctor, and when she finally did stepup to a conversation with him, she made it as brief aspossible. And on that summer night, her brevity mayhave contributed to an unnecessary death.

Wouldn’t it be nice if 100 percent of a doctor’stime was spent on patient care?

No.In fact, it’s that very fantasy that undermines the

effectiveness of many doctors. The belief that anythingthat distracts from spending time on and with patients isnon-value-added is one of the most damaging delusionsin health care today.

Why? Because this belief motivates doctors to minimizethe time and effort they spend influencing the systems theydepend on to deliver the highest quality of care—systemsthat will never live up to their potential without the regularinfluence of the doctors who use them.

The increasing complexity and interdependence ofour hospital systems demand that doctors regularlyengage in some very crucial conversations. It is throughthese conversations that staff, policy, protocols andprocesses are developed. And when doctors minimizetheir involvement in these crucial conversations, the consequences to patients, hospitals and doctors are profoundly negative.

For example, on a summer night in 1994, a nursewas attending to a patient recovering from a colon resec-tion. The incision was large, and the nurse was con-cerned because the wound was opening up. To makematters worse, the patient was nauseous, putting addi-tional stress on the incision.

The nurse called the surgeon who immediatelyexpressed irritation at the interruption of his well-earnedsleep. In her confusion, she hastily and minimallydescribed the situation and left out important informa-tion, leaving the doctor to conclude that the situation wasmanageable if the nurse would simply redress thewound. She did.

The patient later threw up and popped the stitches. Hisorgans spilled onto the bed. And shortly thereafter he died.

So what went wrong here?

Knowing No Boundaries: Five CrucialConversations for Influencing AdministrationBy Joseph Grenny

Learn how physicians who speak up and express dissatisfaction with administrative policies stand thebest chance of changing those policies.

Special Report: Administrator/Clinician Clashes

IN THIS ARTICLE…

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In a recent study of 1,700 doc-tors, nurses, administrators andother clinicians, we found that thiskind of pattern is unfortunately com-mon (see www.silencekills.com). Wefound there are five crucial conver-sations that physicians tend not tohold that undermine their influ-ence, diminish the quality of caretheir patients receive and damagephysician morale.

Furthermore, we found thatdoctors who consistently and effectively held these five crucialconversations reported higher satis-faction in their relationships withhospital staff, better quality of careand higher productivity.

Five crucial conversations

The five conversations doctorstend not to hold, that are profound-ly related to better results include:

1. Concerns with competence—81percent of doctors report havingconcerns with the competenceof at least 10 percent of thenurses with whom they regularlywork. Two out of three doctorshave similar concerns with atleast one other doctor. And asignificant number have seenharm result from these people’sperceived inabilities. And yetfewer than 1 in 12 doctors haveraised concerns with nursingstaff in an effective way despitereporting that the problems havepersisted for 1 to 5 years ormore. If the concerns are withanother doctor, less than 1 per-cent has effectively brought uptheir concerns. The cost of thisfailure is that problems persist,the doctor with the concernsacts out his or her concerns byattempting to work around theproblem, and all too often quali-ty of care suffers.

2. Administrative decisions—93 percent of physicians expressfrustration about decisions

administrators make that affectthem. For example, in one hospi-tal orthopods were greatly affect-ed by a decision to give themtwo rooms instead of three. Andyet less than one in five took thetime to speak to the right peoplein the right way to try to exertinfluence over these decisions.

3. Mistrust of administration—Inthe high stress world of healthcare—particularly with valueslike cost, quality and access inconstant tension—it’s no wonderthat trust issues abound betweendoctors and administrators. Whatcontributes to the intensity of thisproblem, however, is the parties’failure to directly, candidly andeffectively express concernsabout mistrust in a way thatleads to productive solutions. Inthe survey, 97 percent of doctorsreported concerns that adminis-trators fail to consider their inter-ests. And yet most doctors have

only expressed these concerns totheir colleagues or others whohave little influence to makethings better.

4. Staffing problems—More than 80percent of doctors have concernsabout staffing and other obsta-cles that make it hard for themto deliver high-quality care. Forexample, a hospital may be try-ing to use more nurse practition-ers, nurse anesthetists, midwivesor other non-physician careproviders. But once again, veryfew productively and effectivelyinfluence these issues. Some willsend an angry e-mail or com-plain to a medical director. Butfew truly step up to the crucialconversation in a way that yieldsinfluence. The result is that doc-tor influence is minimized andproblems persist. The doctors getmore frustrated. And administra-tors develop a bias for excludingdoctors in future decisions.

Most people labor under the misconception that when others get defensive it’s because the message

was just too tough for them to take. This is largely untrue.

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5. Protocol and process problems—Over two-thirds of doctors reportbeing left out of even clinicaldecisions that directly affectthem. At the same time, the vastmajority of administrators com-plain that their attempts toinvolve doctors are met withresistance, apathy or obstinacy.Who’s right here? In our experi-ence, they’re both right.

The important message here isthat doctors tend not to engage inthese crucial conversations becausethey frequently underestimate theconsequences of not engaging. Ourresearch suggests that they do so attheir peril.

When they minimize involve-ment in improving staff, policies,protocols and processes, theyremove one of the most potent andintelligent sources of influence fromthe systems they depend upon—themselves. The result is that theycontribute subtly—but directly—tothe very problems that hurt themand their patients.

Crucial conversations bestpractices

And yet, the research alsoshows that some doctors do takethe time to step up to these conver-sations. And those who do so skill-fully report better outcomes forthemselves and their patients.

We’ve spent thousands of hoursobserving physicians and otherswho successfully step up to crucialconversations and offer someadvice gleaned from those who doit well.

Some of the advice illustrateshow these skillful doctors think dif-ferently about the conversations.Other elements describe how theyact. Taken together, these best prac-tices increase physician influence ina profoundly positive way.

Consider the risks of not speaking up.

Interestingly, the first differencebetween those who are consistentlyeffective at crucial conversationsand the rest of us is how they thinkabout the conversation itself. Whendeciding whether or not to givefeedback to a less-than-competentpeer, most of us are paralyzed withfear because we immediately thinkof all the bad things that might happen if we speak up.

For example, “They will beoffended. They will begin to bad-mouth us. They certainly won’t agreewith the feedback. So why bother?”A crucial difference of skilled com-municators is that they assess riskcompletely differently from others.They don’t think first of the risks ofspeaking up. They think first of therisks of not speaking up.

Now, they are not foolhardy.They are aware of political sensitivi-ties. But they refuse to make thesesensitivities the sole consideration.It turns out, if you first consider therisks of speaking up, you tend toalmost never speak up. If you thinkfirst of the risks of not speaking up,you will venture forward far moreoften.

Control your emotions by controlling your story.

When we want very badly to

speak up, that’s how we typicallydo it—badly. You can’t producegood outcomes from a crucial con-versation if you can’t get your emo-tions in check first. Never speak upout of anger—the consequence ofdoing so is less, not more, influencein the long run.

The good news is this skill isan exercise of the brain not themouth. Our emotions are not afunction of what is happening out-side us. They are a function of whathappens inside—the stories we tellin our heads about why people aredoing what they’re doing.

The best communicators areconscious of the exaggerated judg-ments and over reactive conclusionsthey tend to draw when someonecauses them pain and inconven-ience. They then challenge thesejudgments by asking, “Why would areasonable, rational and decent per-son do this?” Questions like thisprovoke you to rethink yourassumptions and attributions in away that softens emotions.

Start with safety.

Most people labor under themisconception that when others getdefensive it’s because the messagewas just too tough for them to take.This is largely untrue.

We’ve observed literally thou-sands of crucial conversations andsee almost no correlation betweenthe risk of the message and the ulti-mate success or failure of the con-versation. What does predict suc-cess or failure is how safe you canmake the other person feel whilehearing your message.

Your task in the first 30 sec-onds of a crucial conversation is to

The goal of a crucial conversationis dialogue not monologue.

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ensure the other person knows twothings:

1. That you care about their interests and concerns

2. That you respect them

If you succeed in communicat-ing these two points, they will beable to consider and absorb yourmessage—even if they don’t like it.If you fail to communicate thesetwo things, over 90 percent of thetime they will resist you.

Stick to the facts.

Your next task is to lay out thefactual basis for your concerns. Forexample, if you believe administra-tion is inappropriately leaving youout of decisions, you are obligatedto share concrete examples of yourconcerns. The mistake most peoplemake in this step is that they mix“hot words” in with their facts. Hotwords express your negative judg-ments about the facts.

For example, you might say,“You intentionally scheduled threemeetings on changing feeding pro-tocols in the neonatal unit at timesyou knew I couldn’t attend.” Thehot words here are the accusationsabout administration’s intent behindtheir scheduling activities. Yourjudgments about their intentionsare not facts—they are your opin-ions. They may or may not be true.What is true is that they scheduledthe meetings at times with whichyou had conflicts. This is whatshould be shared first.

As you lay out the facts youcan eventually share why thesefacts concern you, but you’ll do soin a way that allows you to checkyour judgments out with the otherparties rather than communicatethem as accusations.

End with a question.

The goal of a crucial conversa-tion is dialogue not monologue. Onceyou’ve described your concerns, youmust demonstrate your willingness toengage in dialogue by encouragingthe other person to share evenopposing views with you.

We’ve learned through exten-sive observation that people areperfectly willing to let you express astrong opinion so long as they areconvinced you are equally willingto listen to their opposing one. Youcan demonstrate this sincere interestwith a statement like, “Do you seethis differently? I’d very much liketo hear your views.”

Our research suggests that thedoctors who provide the best careare not the ones who spend 100 per-cent of their time on patient care. Itis the ones who willingly spendsome portion of their time holdingconversations that are crucial to con-tinuous improvement in the systemsthat enable high-quality care.

Joseph Grenny is co-author of theNew York Times bestsellers CrucialConversations and CrucialConfrontations. He has consulted withmore than 300 of the Fortune 500 oncorporate change initiatives over thepast 30 years. Grenny can be reachedthrough his company’s website atwww.vitalsmarts.com.