Navigating Stormy Seas: Practical Application of Crucial Conversations

Transcription

1 Navigating Stormy Seas: Practical Application of Crucial Conversations Charin Hanlon, MD, FACP - Program Director, NHRMC, Wilmington NC Heather Tarantino, MD, FACP -4 th Year Clerkship Director, Carolinas Medical Center, Charlotte, NC Elise Drake, PhD - GME Senior Educator, CAMC, Charleston WV Learning Objectives At the conclusion of the session, participants will be able to: List ways to identify high stakes conversations Describe Choosing the What and the If Explain skills used to Describe the Gap Discuss the Six Areas of Influence Make it Motivating

2 Successful Culture A successful culture is like a greenhouse where people and ideas flourish where everybody feels encouraged to speak frankly and openly and is rewarded for sharing ideas What endangers the culture of our training programs? #1 Absence of Trust #2 Fear of Conflict How do we foster a culture of safe communication that builds trust and safely navigates conflict? How can we identify high risk situations?

3 What is a crucial conversation? A discussion between two or more people where: Stakes are high Opinions vary or Emotions run strong Crucial Conversation Algorithm Are there high stakes, opposing opinions, or strong emotions? Recognize the conversation has become crucial Look for red flags that the conversation is unsafe

4 Red Flags to Unsafe Dialogue Desire to avoid a discussion Tension in the room Feeling frustrated, angry or passive aggressive Picking fights Feeling attacked or defensive Dread, nausea, sweating Unhealthy Silence Flight Re-Actions Masking Sarcasm Innuendo Sugarcoating Dropping hints Avoiding Subject change Diversion Not addressing issues Ignoring bad behavior Withdrawal Leave the conversation Physically exiting the room

5 Unhealthy Violence Fight Re-Actions Control Coerce Convince Overstate facts Speak in absolutes Labeling Label people or their ideas with a negative connotation Attacking Belittling Threatening Red Flags to Unsafe Dialogue Trouble ahead So now what??

6 Small Group Activity Divide into small groups Discuss examples of challenging, potentially unsafe resident discussions Choose one example you would like to work on as a group Example should: Be high stakes Have opposing opinions Have strong (or potential for strong) emotions Choosing The What What is really bothering you the most? The action? Its meaning? The violation of the relationship? Summarize the issue in a single sentence (it will never get clearer in the heat of the moment) Consider what you want from the other person and from the relationship

7 Ground Hog Day Repetitive violations of the same rule, despite counseling CPR: C 1 st violation Content - the broken rule P 2 nd violation Pattern you promised to follow the rule and broke the promise. DO NOT ARGUE CONTENT!!! R 3 rd violation Relationship the string of disappointments has violated trust Choosing The If Clearly broken promise = obvious opportunity to address Unclear and iffy If you don t speak: Will you act out nonverbally/passive aggressively? Will your conscience nag you? Are you choosing silence to avoid perceived risk of speaking up? Are you telling yourself you are helpless, nothing you do will help?

8 Master Your Story Fundamental Attribution Error Assumption that people oppose us because they have a personality defect (lazy, selfish, selfcentered, etc) or they enjoy making you miserable The more tainted our history with the person determines how negative is our mental story Our mental story justifies our actions silence or violence Master Your Story - Turn Villains into Humans Tell yourself a complete, accurate story by asking: Why would a reasonable, rational and decent person do what they are doing? This person who is rational is acting irrationally, what am I missing? Make MRI your cultural cornerstone Most Respectful Interpretation Robin Deomeniconi, Elle Group

9 Diagnose Perform your own root cause analysis Consider Six Sources of Influence to a behavior consider all six, even if one seems obvious Six Areas of Influence PERSONAL MOTIVATION 1 Want To ABILITY 2 Can Do SOCIAL STRUCTURAL 3 Peer Pressure 5 Carrots & Sticks 4 Help From Others 6 Environment and Tools

10 Personal Factors 1. Personal Motivation What is the short term motivation to comply? Is it worth the effort? What s the final consequence bundle (riskbenefit analysis)? 2. Personal Ability Do they have the skills and/or knowledge they need? Are they doing the wrong thing because they lack the ability to do the right? Social Factors 4. Social Motivation Is there peer pressure, embarrassment? Does doing the right thing put them at odds with their peers? Am I doing anything to discourage them? 5. Social Ability What help or resources should I be giving to make the job easier? Are others providing necessary tools, help and information?

11 Structural Factors 5. Structural Motivation What are the perks, rewards, benefits? Are the rewards of the wrong thing higher than the right? 6. Structural Ability Are there physical/environmental barriers or inefficiencies? Are bureaucratic barriers getting in the way? Are there policies or rules making the right thing difficult? THE SIX SOURCES MAKE A COMPLETE DIAGNOSIS Describing the Gap Strategy to hold people accountable for their performance and behaviors Gap: expected vs. observed Steps: 1. Articulate observed, contrasted to expected 2. Describe your story (how that impacts you/organization) 3. End with a simple, open ended question to seek out their perspective 4. Add/revise your Six Areas of Influence based on their input

12 Describe the Gap The Facts My Story Questions I ll Ask Expected: Observed: Describe the Gap: Example The Facts My Story Questions I ll Ask Expected: Start rounds by 8 a.m., with pt info ready to present to attending/team. When I see him/her unprepared, it shakes my confidence in independently taking care of patients. what do you think is getting in the way of being prepared to round on time, with all materials ready? Observed: Did not arrive for rounds until 8:45; and did not have relevant pt information This pattern is starting to make me wonder if he/she is struggling with issues outside of rounding. is there something you needed, but didn t have, in order to be prepared and on time?

13 Overdetermine Change Jointly explore ways to improve all Six Areas Of Influence Start by asking for ideas Don t bias the process by giving your ideas/quick fix first Ask and wait for them to share Don t complete the conversation in your head before you listen Goal shared solution that honors your mutual purpose What is your responsibility? Make it Motivating Make it Easier A1 Make it Motivating Open dialogue to find their priorities, motivations and perceived consequences Can you find a motive that resonates with them? Make the invisible visible Articulate short term gain = long term pain Highlight potential long term benefits Allow for Choice Compulsion erases motivation How do you think you can meet my expectations? Stop when you reach compliance Don t sell past the close

14 Slide 25 A1 Author, 8/19/2014

15 Make It Easy Improving Ability Streamline menial tasks Normal people seek ways to make jobs easier, short cuts, ways to avoid noxious tasks. That is not a character flaw!! Use this ingenuity to look for ways to Make it safe to talk about knowledge deficits Question bureaucracy Why do we have to do it that way Make sure people have access to the right data/metrics Agree on A Plan What is the Scorecard? Four Key Elements Who Responsible party and additional team members Does What Specific actions that are in their control By When Be as specific as possible date and time (Friday at 4pm vs end of the week) Follow up Set up a clearly defined time to meet to ensure the plan is completed/ behavior has not recurred Finally, summarize the plan

16 Conclusions Recognize crucial conversations Choose the What and the If Master your story consider six areas of influence Describe the gap Listen Diagnose all Six Areas of Influence Make it Motivating and Easy Make a Plan Bibliography Patterson K, Grenny J et al (2012). Crucial Conversations Second Edition. US: McGraw-Hill Books. Patterson K, Grenny J et al (2013). Crucial Accountability. US: McGraw-Hill Books. Bryant, A (2014). Quick and Nimble. NY: Times Books. Lencioni, P (2002). Five Dysfunctions of a Team. San Francisco: Jossey- Bass Books. Miller,W, Rollnick, S (2013) Motivational Interviewing,Third Edition: Helping People Change. NY: Guilford Press. Rosengren, D (2009) Building Motivational Interviewing Skills. NY: Guilford Press.