Messy moments: Filling in

The practice triage nurse called in ‘sick.’ As the leading practice MD, you told the Nurse Practitioner to triage today.

She didn’t triage at all!

Patients in the waiting room waited a long time! You saw one patient too late to arrange referral appointments.

At the end of the clinic, you complained to her about the chaos in the clinic. She never even told you about the problems.

She apologized and excused herself quickly.

What do you as the MD want to happen here?

• You want the clinic to run well
• When you assign tasks to your staff, you want them to do it and do it well
• You also wish people showed up reliably, so you wish they were happier at work
• It looks like you’ll have to repair your relationship with the NP

What can you do here to get better results?

1. Repair your relationship with the NP

• Slow things down Suggest you two get together later to talk about how to deal with this in the future. Ensure she knows it’s a forward-facing conversation, not to criticize.
• Get curious
  • Notice your thoughts and feelings about clinic. What do these tell you about yourself? How did they influence your work and relationship with the NP?
  • For just a moment, imagine that you were totally responsible for what happened. Don’t worry: that’s almost never possible! Just think about what if you alone caused the problems. What would you do to make sure it doesn’t happen again?
    • Think about how you originally solved the triage nurse’s absence.
    • Think about what you can do to cope with staff shortages if you were responsible for actions and outcomes.
    • Knowing many others are involved, what seems important to do next? Who else should you involve?
  • Get curious about the NP. From her point-of-view, what are her challenges, motivations, feelings? She had a c full day of appointments before you told her to triage. Had she ever triaged before? Did she know what to do? She looked stung by the criticism. It sounded like blame. She probably felt ashamed. And also silenced: she was directed to take the responsibility. Not asked.
    • What do you want to learn from her when you talk about the situation?
• Show compassion Recap what she told you about clinic and her feelings so she knows that you heard her. Specifically appreciate her as a pro and as a person in the practice.
• Strengthen your relationship Tell her how you rely on her, her human qualities as well as her knowledge. Open the communications between you. She needs to know that you are available to her and expect her to tell you about problems. Clarify other expectations you have of her. Many do not know this.
• Navigate with her
  • Decide what each of you will do the next time the triage nurse is out - there will be a next time! Together laser-focus on the tasks and responsibilities each of you can take to handle the gap well. She needs to know clearly where she has autonomy and where she needs to consult with you or others. This conversation tells her that you listen to her and you’re in this with her.
  • Ask what you can do with her to make her days more doable and enjoyable (!).

2. Discuss distribution of triage tasks with the practice team [because they were confused and concerned too] One person’s absence ripples across everyone. A team meeting can uncover more about who is affected by this absence and who might better take on tasks.

• Identify key tasks, overlaps and handoffs List these in context of specific practice objectives… and ensure everyone agrees with those objectives. Surface possible obstacles.
• Decide who takes the tasks of the absent person. This triggers lots of questions:
  • What’s the purpose of the task?
  • What does the task done well look like?
  • What skills or information are needed to do it? How can others learn enough to fill in successfully?
  • When there’s a problem who can help?
  • How critical is the task?
  • Who can manage the additional responsibility most easily with their other tasks?
• Communicate clear expectations
  • What success looks like
  • Consequences for success and failure
  • Task deadlines
  • Identify who can help when you’re uncertain or unable to perform a task
  • Clarify the limited accountability that is individual. But most problems are systemic
  • Guarantee psychological safety – everyone’s responsibility
  • Obligation for all members to ask question and voice uncertainties and concerns
• Periodically check-in with team. Discuss how adapting to absences is working. Invite questions and comments (negative and positive). Find out what each individual needs to succeed. Then adapt task distribution.

What does this do for me?

• Better workflow because everyone knows the linkages, hand-offs and obstacles. Because they investigated it together!
• Reduces staff confusion and uncertainty, so reducing conflict and missteps because they understand the task relationships and responsibilities
• Better performance because your practice team know where they have autonomy and where to hand-off or cooperate. And they inform you better
• Your staff stays in the game and communications remain open because there’s a good conflict process
• Engage millennials This is just the kind of learning and collaboration they expect
• Everyone learns through disagreement and discussion when it’s safe to be candid and follow-up is transparent. Comfortable disagreement and discussion prove critical to handle tension, uncertainty, complexity and change
• Reduce the havoc and stress of an absence because everyone is prepared
• Soften blame and shame because all see the systemic nature of failures
• Staff engage more fully because they feel supported and a valued part of the team
• People more reliably show up at work and want to stay

TIPS

1. Distributing work in the team requires the right person, the right task, and the right supervision.
2. Clear expectations proves critical to team success, according to Gallup Poll research. They bring all together on goals and priorities, boundaries, shared responsibility.
3. Time-outs: Encourage everyone to call timeout when they see potentially harmful things. These both pause the action and bring everyone into the problem. You open a channel of communication. You reduce the chance that a problem will blow up. And you build trust.
4. Make it as simple as possible for people to get comfortable with conflict because it’s inevitable. The aim is productive relationships – and the opportunity to continue to talk. Interpersonal relationships of respect, communication and awareness are highly correlated to excellent S&Q performance in primary care practices.

RESOURCES

• TeamSTEPPS for Office-based Care: Leading Teams. https://www.ahrw.gov/teamstepps/officebasedcare/module4/office_lead-ig.html
• The importance of constructive conflict process and culture:
  • Davey, L. 2019. The Good Fight: Use Productive Conflict to Get Your Team and Organization Back on Track
  • DeChurch et al. 2013. Moving beyond Relationship and Task Conflict: A Process-State Perspective. Journal of Applied Psychology 98 (4):559-578

Is confusion or conflict in your practice making you crazy? Tell me about it! Nance.goldstein@post.harvard.edu