Negotiation

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Conflict ResolutionA Core Leadership Attribute
Seminar on Negotiation

• Created By
• Gus M. Garmel, MD, FACEP, FAAEM
• Clinical Professor, Department of Surgery
• Co-Program Director, Stanford/Kaiser Emergency
  Medicine Residency
• Stanford University, Palo Alto, California
• Tenet Editor
• Barbara Blok, MD, FACEP
• Assistant Director, Denver Health Residency in
  Emergency Medicine
• University of Colorado School of Medicine,
  Aurora, Colorado

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Course of Conflict
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Outline

• Definitions Relevance
• Types Factors of Conflict
• Conflict Resolution
• Keys Principles
• Barriers
• The Art of Communications
• Process of Negotiation

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Conflict

• Any situation where incompatible activities,
  feelings, or intentions occur together.
• A competitive or opposing action of
  incompatibles an antagonistic state of action
  (divergent ideas, interests, or persons).
• Mental struggle resulting from incompatible or
  opposing needs, drives, wishes, or external or
  internal demands.

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Conflict Resolution

• A range of processes aimed at alleviating,
  eliminating, or resolving conflict or its
  sources.
• The methods and process of negotiation,
  arbitration, and institution building which
  promote the peaceful ending of social conflict
  and war.

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Negotiation

• A dialogue intended to
• Resolve disputes
• Agree upon course of action
• Bargain for advantages
• Satisfy various interests

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RelevanceModel of the Clinical Practice of
Emergency Medicine
COMMUNICATION AND INTERPERSONAL SKILLS
ISSUES Complaint Management Conflict
Resolution Interdepartmental and Medical Staff
Relations Team Building Teaching

• Created through collaboration of ABEM, ACEP,
• CORD, EMRA, RRC-EM, and SAEM

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Relevance- For Emergency Medicine

• Conflict is often outcomes-driven and not
  process-driven
• Physicians are typically goal-oriented
• EPs want to win desire control
• EPs focus on immediate outcomes (want things to
  happen now)
• great for patients
• challenging for administrators/consultants

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Relevance- For Emergency Medicine

• Salaries Schedules
• Positions promotions
• Patient care
• Interpersonal interactions
• Medical legal protection
• Professional satisfaction
• Career security

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Relevance- Example

• An emergency RN will not perform a certain task
  you have requested because she doesnt feel it is
  necessary. You are a good clinician, but you have
  a reputation in your ED as being difficult.

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Relevance- Example

• 76 year old female who doesnt feel well is
  brought to the ED by her adult son. Her entire
  work-up is negative, but the son wants her
  admitted, despite no medical nor social
  indication.

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Relevance- Example

• A consultant doesnt think that he needs to see
  the patient you are calling about at 1 AM. You
  dont know this individual, but youve heard he
  is not well-liked by your colleagues.

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Conflict is Inevitable
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Why Do We Conflict?

• Personal differences
• Information deficiency
• Role incompatibility
• Environmental stress

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Types of Conflict

• Intrapersonal
• Interpersonal
• Intragroup
• Intergroup

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Types of Conflict- Intrapersonal conflict

• Conflict within
• Example
• Conflict in dealing with a particular type of
  patient

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Types of Conflict- Intragroup conflict

• Conflict between individual group members
• Example
• Your colleague always grabs the sickest patients
  and major resuscitations

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Types of Conflict- Intergroup conflict

• Conflict between 2 groups of people
• Example
• Who performs the ED thoracotomy in a trauma
  resuscitation (EM vs. Surgery)

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Types of Conflict- Interpersonal conflict

• Conflict between 2 persons
• Example
• Conflict with a patients family member or nurse

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Factors in Conflict

• Personal Attributes
• Gender
• Ethnicity/Culture

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Factors in Conflict- Personal Attributes
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Factors in Conflict- Personal Attributes

• Keirseys 4 Temperaments

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Factors in Conflict- Personal Attributes

• Keirseys 16 Categories

ARTISAN GUARDIAN IDEALIST RATIONAL
Promoter Supervisor Teacher Field marshal
Crafter Inspector Counselor Mastermind
Performer Provider Champion Inventor
Composer Protector Healer Architect
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Enneagram- Personality System
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Enneagram- Personality System
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Factors in Conflict- Gender
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Factors in Conflict- Gender
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Factors in Conflict- Ethnicity Culture

• Language
• Behavior nuances
• Negotiation style
• Passion
• Tempo
• Culture
• Custom

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Conflict Resolution
How do we get there?
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Conflict Resolution- The keys principles

• Gain insight
• Truth always
• Seek wisdom
• Never criticize
• Offer assistance

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Conflict Resolution- The keys principles
Garmel GM. Conflict Resolution in EM. In Adams
Emergency Medicine (Elsevier), 2008.
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Conflict Resolution- The keys principles
Garmel GM. Conflict Resolution in EM. In Adams
Emergency Medicine (Elsevier), 2008. Adapted
from Ahuja J, Marshall P. Conflict in the
emergency department Retreat in order to
advance. Can J Emerg Med 20035429-433.
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Conflict Resolution- The keys principles
(Coveys Habits)

1. Principles of personal choice - Be proactive
2. Principles of personal vision - Have the end in
   mind
3. Principles of integrity execution - First
   things first
4. Principles of mutual benefit - Think win/win
5. Principles of mutual understanding - Seek first
   to understand, then to be understood
6. Principles of creative cooperation Synergize
7. Principles of balanced self-renewal - Prepare
   learn the skills
8. Find your voice and inspire others to find
   theirs

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Conflict Resolution- Barriers

• Preformed judgments
• Poor communication skills
• Cultural/gender barriers
• Lack of understanding of both sides
• Not possessing the right skill set
• Not understanding negotiable vs. non-negotiable
• Pride

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Conflict Resolution- Barriers

• Cynicism
• Criticism
• Comparing
• Competing
• Complaining
• Contending

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Conflict Resolution- Pearls

• Plan ahead for all possible outcomes
• Know related policies procedures
• Respect your primary responsibilities
  obligations
• Seek to Gain consensus, not to prove a point
• Recognize that the truth lies somewhere in the
  middle

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The Art of Communication

• Effective Communication
• is essential for
• Conflict Resolution

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The Art of Communication

• Avoid (Obvious) Pitfalls
• Im the attending!
• Because I said so!
• Im right! (or, Youre wrong!)
• My way is the only way!
• Youre just a nurse/tech/NP/internist!
• Youre an XXXXX !

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The Art of Communication

• Strive to find mutual understandings
• I can see your point, but I dont feel you are
  considering mine.
• Lets discuss this a bit more from the patients
  perspective.
• Ive always respected (appreciated) your
• It seems that we disagree, which is fine, but Im
  just not comfortable with

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The Art of Communication- Effective vs.
Ineffective

• Effective
• Smile
• Eye contact
• Avoiding emotion
• Active listening
• Concentration
• Attention
• Focused

• Ineffective
• Snarl
• Arms across chest
• Finger pointing
• Pacing
• Distracted
• Inattention
• Disengaged

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The Art of Communication

• Negotiation is the art of
• letting them have your way.

- Daniel Vare
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The Art of Communication

• Let us never negotiate out of fear -
• But let us never fear to negotiate.

- President John F. Kennedy
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Process of Negotiation- The definition revisited

• Negotiation is a dialogue intended to
• Resolve disputes
• Agree upon course of action
• Bargain for advantages
• Satisfy various interests

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Process of Negotiation- Objectives

• Mutually satisfactory structure
• Executed agreement
• Lasting and mutually beneficial relationship
• Comfort with process and outcome
• Accounts for feelings

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Process of Negotiation- Stages
Adapted from Shell R. Bargaining for
Advantage Negotiation Strategies for Reasonable
People. 1999
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Process of Negotiation- Outcomes
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Process of Negotiation- Steps to success

• Have a plan
• Broad to narrow
• Actively listen learn
• Take notes
• Unbundle issues
• Paraphrase dont parrot

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Process of Negotiation- Timeline

• Initial - assess situation, gather information
  (from multiple sources), establish trust, build
  the relationship
• Middle - patience, gather facts, consider
  counteroffers, mutual concessions
• End - accept, get mediator, walk away, follow-up,
  be gracious and complementary

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Process of Negotiation- Responses
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Process of Negotiation- Styles
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Process of Negotiation- Principled negotiation

• An interest-based approach to negotiation
  focusing primarily on conflict management and
  conflict resolution.
• Uses an integrative approach to find a mutually
  shared outcome

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Process of Negotiation
Focus on the issues, not positions
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Process of Negotiation- BATNA?

• Best Alternative To a Negotiated Agreement
  (BATNA)
• What will happen if negotiations fail?
• Your course of action
• Their likely course of action

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Process of Negotiation- BATNA

• Develop your BATNA and attempt to determine
  theirs
• Only reveal your BATNA if it is better than
  theirs
• Consider accepting terms when their proposal is
  better than your BATNA
• Reject terms when their proposal is worse than
  your BATNA

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Process of Negotiation - Barriers

• Emotions
• Fear Anger
• Difficult Questions
• Difficult Personalities
• Complex Situations

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Process of Negotiation - Barriers Emotions

• Fear is like fire. If controlled it will help
  you if uncontrolled, it will rise up and destroy
  you. Men's actions depend to a great extent upon
  fear. We do things either because we enjoy doing
  them or because we are afraid not to do them.

- John F. Milburn
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Process of Negotiation - Barriers Difficult
Questions

• Defer
• Deflect
• Delay
• Decline

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Process of Negotiation - Barriers Difficult
Personalities

• Often unavoidable
• May result in or escalate conflict
• Individual may have a position of authority
• Strategies
• Dont reciprocate/stay positive
• Deal only with YOU
• Take a surprising step

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Process of Negotiation - Barriers Complex
Situations

• Repeat over time
• Multi-issue
• Multi-party
• Intangible factors
• Intra-organizational
• Tangible factors

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Process of Negotiation- Effective Strategies

• Prepare in advance
• Understand what is and isnt negotiable
• Practice
• View negotiation process as ongoing
• Follow up on the negotiation

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Process of Negotiation- Pearls

• Find (and point out) common ground
• Understand your counterparts perspective
• Work to shape their decision
• Allow the other side to save face
• Get them to think it was their idea!

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Process of Negotiation- When You Need Help

• Seek assistance from a trusted colleague or
  supervisor
• Refer to hospital bylaws and policies
• Contact Human Resources
• Call in mediator (or arbitrator)
• Walk away
• Dont bring it home

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Process of Negotiation- Achieving Successful
Outcomes
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Summary Points

• Conflict is inevitable
• Do your homework
• Identify personal attributes
• Avoid emotional investment
• Listen carefully to what is said
• Dont burn bridges
• Understand your BATNA (and theirs)
• Practice principled negotiation

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Final Remark

• Successful conflict resolution can be
  challenging because it has so many elements and
  possibilities, yet it undeniably plays a large
  role in an emergency physicians daily and career
  activities.

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National Residency Leadership CurriculumQuestions
?
?
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National Residency Leadership CurriculumSpecial
Thanks!

• Funded By
• An American College of Emergency Physicians
  Chapter Grant
• Endorsed By
• American College of Emergency Physicians
• Emergency Medicine Council of Residency Directors
• Emergency Medicine Residents Association
• Society for Academic Emergency Medicine

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National Residency Leadership CurriculumSpecial
Thanks!
Senior Editors Stephen Wolf, MD, FACEP Andrew
French, MD Matthew Mendenhall, MD, MPH Tenet
Editors Britney Anderson, MD Barbara Blok, MD,
FACEP Jeffrey Druck, MD, FACEP Maria Moreira,
MD Lee Shockley, MD, MBA, FACEP Administrative
Editor Barbara Burgess
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National Residency Leadership CurriculumThank
You!
For More Information Please Visit www.DenverEM.or
g www.CoACEP.com