Staff in Conflict

"I have a problem employee. Although I've asked her to follow a certain rule, she always violates it."

"The front office never knows what the back office is doing and vice versa. It causes a lot of tension."

"What does it cost me each time I lose an employee? We've seen some turnover this year because people can't get along with a certain long-term staffer."

Do any of these complaints sound familiar? They should. In fact, these are real-life examples of staff conflicts from medical practices that wrote to www.PhysiciansPractice.com asking for help resolving them.

"When there are problems among employees, they can be more challenging to fix than information systems snafus or mechanical problems," notes Tim Hicks, director of Vancouver-based Connexus Conflict Management, which provides mediation services to businesses, corporations, and families.

People tend to run away from conflict, he says, and view it as a sign of failure. The reality is, conflict is "part and parcel of our living together," according to Hicks. Groups can use it as a positive way to come up with solutions to problems like disagreements over how a job should be performed, or who should be performing it. And when staff conflict is causing problems and needs resolving, there are steps you can take to ease an often-uncomfortable process.

First, be a listener

The same approach you use to diagnose patients - gathering information and making concrete suggestions based on your observations - works with resolving staff conflicts, too.

"I always tell physicians, 'Your ears are much more effective communication devices than your mouth,'" says Jay Justice, senior vice president and partner at Cejka & Co., healthcare consulting division in St. Louis. Justice has worked with practices of all sizes, from single-specialty groups of five or six physicians to large physician networks of 3,500.

Justice firmly believes that, on the business side of the practice, "diagnose, prescribe, and treat" works. From a medical standpoint, you want patients to visit on a regular, preventive basis. Likewise, it's best to deal with staff issues "long before they are issues," says Justice. "If you see someone not doing appropriate work or treating patients poorly, you must intervene. If the only time you respond to employee concerns is when somebody has a problem, you are failing as an organization."

To avoid the appearance of taking sides in a conflict, meet with all of the involved parties together, Justice suggests. "If you've got two parties squabbling and both of them aren't in the room," he notes, "you can't have a good conversation. You can't get caught in he said, she said."

"Protected issues" such as age discrimination or sexual harassment should involve legal counsel. Otherwise, practices should try to resolve problems internally whenever possible. Justice's caveat? "Make certain that you've selected the right day-to-day leadership.

"In a lot of practices, physicians have appointed nursing leadership or other clinicians in roles of people management. But what makes someone a good clinician is the ability to do things to a certain standard. In managing people, it's not all black and white; there's a lot of gray. You can't manage people like you manage functions," says Justice.

Solo or team approach?

Often the size of the practice will dictate the extent to which the physician is directly involved in settling disagreements. In a small practice, the physician may need to take on the role of observer and mediator, which may be difficult for some docs. For physicians who feel uncomfortable dealing with personality conflicts, Justice suggests consulting with a colleague who is strong in this area, or talking to human resources leaders if you are affiliated with a health plan or hospital. Or, he says, "try to find courses on effective management. It's OK to start with elementary skills. This is day-to-day, basic people management."

Even if there is room for a dedicated administrator, the physician needs to remain involved, observing how well the practice operates, how people interact, and whether problems are dealt with quickly.

"For the doctor to say 'that's not my problem' is the wrong thing to do. They're going to deal with the consequences of poor staff performance, dissatisfaction - all that is going to translate into how care is rendered and how effectively the practice runs," observes Justice.

Hicks believes physicians should try to avoid being the primary contact for resolving conflicts. "It's not wise to have physicians be the ones doing internal facilitation," he says. "To begin with, they are seen as the boss, the authority. Besides, they are very busy and stressed. You need someone who can calmly take the time to deal with [these problems]. Human resources is a good place to have that and they have some training in human relations."

Dale Shimko, president and senior consultant of Performance Alignment Systems, an organizational behavior services firm in Nashville, agrees that for the most part, physicians should take a supporting role.

"They get bogged down in things like this. They keep reinforcing the dependency that staff has on them," he says. "What they need to be doing is help staff to become more self-sufficient. Getting staff working together decreases the amount of time taken from practicing medicine."

Adds Lorraine Lansing, an Edmonds, Wash.-based practice administrator with a staff of 17, "I encourage staff to deal with conflicts immediately with their co-worker. They come to me if they are uncomfortable dealing with an issue or can't seem to resolve it. For the most part, physicians are not good personnel managers."

Once it's determined who will be responsible for observing staff and stepping in when necessary, be consistent in using that person in that role. "If the practice has an administrator who deals with this on a daily basis," says Justice, "the worst thing the physician can do is let people run around that individual to get to the doctor. The physicians have to provide counsel and guidance to the administrator and direct people to deal with the process that's in place. The physician is the ultimate authority, but come to him at the right point in time."

Lansing takes it a step further: "At our practice, staff is never to approach a physician with co-worker conflicts."

Getting help can help

Although the experts agree that office conflicts should be handled as quickly and at the least formal level as possible, outside help can be a good solution if "the difficulties are more than the people involved can handle," says Hicks. This is not unusual in medical practices where "the pressures are different and greater than in many other organizations. They are dealing with life and death situations, with people's health. The customers are coming at the practice with a different set of expectations, demands, and needs than in other organizations," he adds. "The fast pace is another element. If practices are not addressing the kinds of pressures that result from that, it makes it harder" to resolve internal problems.

The truth is, most conflicts do not truly stem from the people involved, but the structure they work in. Consider whether there are clear definitions about job responsibilities and how work gets done, if there are too many meetings (or too few), and whether there are adequate lines of communication in general.

For example, Lansing says her check-out and reception staffers "were complaining that they each did more work than the others, and that their job was just plain harder. So I assigned specific duties to each desk and had them rotate desks weekly. In order to get buy in, I involved each of them in the desk duty assignment process. It worked well, and when someone is out, now the others know what needs to get done."

Shimko points to a case in which a small practice uncovered inappropriately assigned job duties as the source of squabbles and inefficiencies. A physician had started a solo practice after her former employer, a group clinic, disbanded. She brought with her a nurse and two front-office people, only to find tensions high and workflow faltering after just a few months. Shimko suggests the switch from large group to small was revealing.

In larger groups, he says, "roles are more specialized, job descriptions are narrower. Sometimes inadequacies get covered up." In a smaller practice, however, each person "was so critical for success, there was no hiding place. They had to work more efficiently together and with a broader range of duties." Meanwhile, Shimko adds, the doctor was being pulled into the day-to-day problem solving; it was taking away from patient time.

After spending about an hour with each person in the practice, testing both cognitive abilities and personality traits, Shimko recommended a "staff shuffle." What he discovered was that the receptionist was "better at cranking out numbers" whereas the other supporting staff "got her energy from interacting with people. It was a win-win switch," he says.

Get started

The higher your authority in an organization, the more aware you are likely to be of how time-consuming these problems are. "You just want them to go away so you can get on with the business at hand," says Hicks. In fact, surveys of human resource professionals report that people in leadership roles spend about 20 percent of their time dealing with conflict, and that about 60 days of productivity per year are lost as a result of conflict and misunderstandings among co-workers and between employees and their bosses.

It doesn't have to be that way, insists Justice. "Think about someone who comes in with high cholesterol. You can deal with that before they come in needing bypass surgery." He says that "by intervening early and solving problems before they become a crisis, you will have a complete atmosphere of openness where people can talk freely, and your time and energy is spent on minor issues" among staff.

Hicks adds that "Physicians need to look at their own style of management and how they communicate with staff. Every manager wants the people working for them to take more responsibility, to be more creative, to take initiative, and to contribute. People are going to do that more if they like the way the operation is working."

Joanne Tetrault, managing editor for Physicians Practice, can be reached at jtetrault@physicianspractice.com.

This article originally appeared in the September/October 2002 issue of Physicians Practice.