INDICATORS OF SUCCESS: AN EXPLORATION OF SUCCESSFUL CONFLICT MANAGEMENT IN

US HOSPITAL SETTINGS

+"
A Thesis submitted to the Fa u!t" o# the

G$aduate S hoo! o# A$ts a%d S ie% es o# Geo$&eto'% U%i(e$sit" i% )a$tia! #u!#i!!me%t o# the $e*ui$eme%ts #o$ the de&$ee o# Maste$ o# A$ts i% Co%#!i t Reso!utio%

Pau! Cha$!to%, +-A-

.ashi%&to%, DC /u%e 01, 2303

Indicators of Success: An Exploration of Successful Conflict Management in US Hospital Settings

Pau! Cha$!to%, +-AThesis Ad(iso$: A!a% Tid'e!!, PhD A+STRACT

This )a)e$ i%(esti&ates ho' su ess is de#i%ed i% ma%a&i%& hea!th a$e o%#!i ts- It i%t$odu es a #$ame'o$4 #o$ a%a!"5i%& the di##e$e%t o%#!i t ma%a&eme%t d"%ami s i% hea!th a$e, di(idi%& o%#!i t i%to #ou$ mai% ate&o$ies based o% the )a$ties i%(o!(ed: )$o(ide$6)$o(ide$7 )atie%t6)$o(ide$7 )$o(ide$6admi%ist$atio%7 )atie%t6)a"e$- Re(ie's o# the !ite$atu$e a%d i%te$(ie's 'ith te% hea!th a$e o%#!i t ma%a&eme%t )$a titio%e$s 'e$e used to a%a!"5e these #ou$ d"%ami s a%d ide%ti#" 4e" #eatu$es o# the o%#!i ts a%d o%#!i t ma%a&eme%t $es)o%ses asso iated 'ith ea hThe i%te$(ie's #u$the$ e8)!o$ed de#i%itio%s o# su ess, !a$i#ied t$ai%i%& a%d $esea$ h %eeds, a%d ide%ti#ied eme$&i%& t$e%ds i% the #ie!d-

The #i%di%&s su&&est that di(idi%& hea!th a$e o%#!i t i%to $e!atio%shi)6based ate&o$ies o# o%#!i t is a))$o)$iate due to si&%i#i a%t di##e$e% es i% the t")es o# o%#!i t e8)e$ie% ed i% these d"%ami s a%d the o$$es)o%di%& di(e$&e% e i% o%#!i t ma%a&eme%t &oa!s, #o us, a%d i%te$(e%tio%s- Co%#!i t ma%a&eme%t a))$oa hes i% the #ou$ d"%ami s !a$&e!" sha$ed the aims o# im)$o(i%& $e!atio%shi)s, im)$o(i%& ommu%i atio%, a%d sa(i%& mo%e", thou&h ea h d"%ami i% !uded additio%a! aims- S)e i#i de#i%itio%s o# su ess (a$ied, at times 'ide!"- The$e 'e$e %ote'o$th" di##e$e% e i% o%te8t a%d )e$s)e ti(e bet'ee% t'o o# the !a$&est ate&o$ies o# hea!th a$e o%#!i t, )atie%t6)$o(ide$ o%#!i t a%d )$o(ide$6)$o(ide$ o%#!i t- Patie%t6)a"e$ o%#!i t i%te$(e%tio%s di(e$&ed #$om the othe$s i% bei%& !ess $e!atio%a! a%d mo$e t$a%sa tio%a!- Ea$!" i%te$(e%tio% i% o%#!i t ma%a&eme%t 'as im)o$ta%t i% a!! d"%ami s-

Ho' )$o&$ams de#i%e su ess has im)!i atio%s #o$ ho' hos)ita!s desi&% o%#!i t ma%a&eme%t s"stems- The !ite$atu$e $e(ie' su&&ests that the o$ie%tatio% o# ma%" e8isti%& hea!th a$e o%#!i t ma%a&eme%t )$o&$ams ma" o(e$!oo4 e$tai% o%#!i t d"%ami s, u%i%te%tio%a!!" !ea(i%& e$tai% t")es o# o%#!i ts u%add$essed-

ii

The o%#!i t d"%ami #$ame'o$4 )$ese%ted he$e a% he!) desi&% o%#!i t ma%a&eme%t s"stems that a)tu$e the b$eadth o# hea!th a$e o%#!i ts i% mo$e i%te&$ated 'a"s-

Im)o$ta%t t$e%ds i% hea!th a$e o%#!i t ma%a&eme%t ide%ti#ied b" the $esea$ h i% !ude a shi#t a'a" #$om i%te$est6based %e&otiatio% mode!s to'a$ds $e!atio%shi)6based a))$oa hes to o%#!i t ma%a&eme%t7 a $eo$ie%tatio% to'a$ds )$e(e%tio% a%d ea$!" i%te$(e%tio%, $aisi%& e8)e tatio%s that hea!th a$e )$o(ide$s ta4e the !ead o% o%#!i t e%&a&eme%t a%d i% $easi%&!" su))!a%ti%& thi$d6)a$t" i%te$(e%tio% mode!s7 a )ush to i% !ude o%#!i t ma%a&eme%t t$ai%i%& i% hea!th )$o#essio%a! s hoo!s7 a%d uti!i5atio% o# a %ested t$ai%i%&6me%to$i%&6 ommu%ities o# )$a ti e a))$oa h to de(e!o)i%& hea!th a$e )$o(ide$s9 o%#!i t ma%a&eme%t s4i!!s-

iii

TABLE O CO!TE!TS

Pa&e

1. I%t$odu tio% ::::::::::::::::::::::::::--- 0

2 ; = Resea$ h Desi&% ::::::::::::::::::::::::: Co%#!i t i% Hea!th a$e ::::::::::::::::::::::: Co%#!i t Ma%a&eme%t i% Hea!th a$e -::::::::::::::::: ; < 0 =

5. Lite$atu$e Re(ie' ::::::::::::::::::::::::-- 21

P$o(ide$ > P$o(ide$ Co%#!i t ::::::::::::::::Patie%t > P$o(ide$ Co%#!i t ::::::::::::::::: Patie%t > Pa"e$ Co%#!i t ::::::::::::::::::P$o(ide$ > Admi%ist$atio% Co%#!i t :::::::::::::: <- I%te$(ie' Resu!ts ::::::::::::::::::::::::: 2 1 2 ? @ 2 @ = @ A

7. Dis ussio% :::::::::::::::::::::::::::-- AA

Mai% D"%ami s i% Hea!th a$e Co%#!i t ::::::::::::-De#i%itio%s o# Su ess ::::::::::::::::::: A A ? 3 ? ; ? = ? < 0 3 2 0 3 @

Theo$eti a! Shi#t To'a$ds Re!atio%a! Mode! ::::::::::Ea$!" I%te$(e%tio%: Hea!th Ca$e .o$4e$s as the F$o%t Li%e ::::-Edu atio% a%d T$ai%i%&: O))o$tu%ities to C$eate Positi(e Cha%&e :--Me$&i%& the Cu!tu$es o# Hea!th Ca$e a%d Dis)ute Reso!utio% :::-Su&&ested Futu$e Resea$ h :::::::::::::::::

8. Co% !usio% :::::::::::::::::::::::::::- 002 9. +ib!io&$a)h" :-:::::::::::::::::::::::::-- 00=

i(

I!T"O#UCTIO!

The &e%esis #o$ this thesis a$ose #$om 'hat I %oted as a te%de% " #o$ autho$s o$ )$a titio%e$s to #o us o% o%e )a$ti u!a$ o%#!i t d"%ami 'ithi% hea!th a$e, o#te% to the $e!ati(e e8 !usio% o# othe$ d"%ami sSimi!a$!", ma%" o%#!i t ma%a&eme%t s"stems estab!ished i% hos)ita!s that I su$(e"ed seemed to o%!" dea! 'ith a e$tai% t")e o# om)!ai%t- .hi!e )$o&$am #o us is desi$ab!e i% o$de$ to e%su$e *ua!it" out)uts, the $est$i ted ho$i5o% o#te% seemed to a$ise u%i%te%tio%a!!"- As a $esu!t o# this te%de% " to Bsi!oC )$o&$ams a%d a ti(ities, ma%" o%#!i t d"%ami s $is4 bei%& !e#t u%$e o&%i5ed a%d u%add$essed-

Re!ati(e!" !itt!e $esea$ h has attem)ted to s)a% o$ om)a$e the di##e$e%t domai%s o# hea!th a$e o%#!i t ma%a&eme%t to see ho', a%d ho' 'ide!", hos)ita! ADR )$o&$ams a$e #o usi%& o% these di##e$e%t d"%ami sIt is i% this om)a$ati(e e8ami%atio% that this thesis mo(es the e8isti%& $esea$ h #o$'a$d-

The$e is a st$o%& ase to be made that o%#!i t d"%ami s i% hea!th a$e s"stems a$e i%te$ o%%e ted a%d i% a)ab!e o# bei%& se)a$ated i%to dis $ete )a$ts- I% su h om)!e8 s"stems, it is o#te% %ot )ossib!e to #u!!" disa&&$e&ate the ausa! #a to$s o# a%" e(e%t- Co%#!i t i% hea!th a$e is %o di##e$e%t- U%$eso!(ed o%#!i ts $eate $i))!e e##e ts that im)a t out omes #a$ $emo(ed #$om the i%itia! dis)ute- Di##e$e%t !a"e$s o# i%di(idua!s a%d s"stems i% o%#!i t $eate a om)!i ated 'o$4 e%(i$o%me%t, 'ith i%te$'o(e% auses a%d e##e ts o# ma%" dis)utes-

The be%e#it o# ma))i%& a%d stud"i%& di##e$e%t hea!th a$e o%#!i t d"%ami s is to )ai%t a #u!!e$ )i tu$e o# the $e!atio%shi)s a%d t")es o# o%#!i ts that %eed to be ma%a&ed i% hea!th a$e- A$ti#i ia!!" iso!ati%& ate&o$ies o# o%#!i ts he!)s us e8ami%e i# a%d ho' the" a$e bei%& add$essed i% a s)e i#i hea!th a$e e%(i$o%me%t- Fo used )$o&$ams 'i!! !i4e!" sti!! %eed to be desi&%ed to dea! 'ith disti% t issues, but this o%#!i t ma) he!)s de isio% ma4e$s e%su$e that othe$ )$o&$ams e8ist to add$ess the additio%a! dis)utes- +e"o%d this, a hea!th a$e o%#!i t ma) he!)s !i%4 )$o&$ams to&ethe$ 'ithi% a b$oade$ o%#!i t ma%a&eme%t s"stem #o$

i% $eased s"%e$&"- I%%o(ati(e hea!th a$e dis)ute $eso!utio% )$o&$ams 'i!! i% $easi%&!" attem)t to add$ess the s)e t$um o# o%#!i ts i% su h a% i%te$$e!ated, om)$ehe%si(e ma%%e$-

Pa$t o# u%de$sta%di%& the o%te8t a%d im)!i atio%s o# di##e$e%t o%#!i t d"%ami s i% hea!th a$e is the issue o# di##e$i%& de#i%itio%s o# su ess- C!a$it" o% ho' su ess is de#i%ed a%d measu$ed is

a %e essa$" om)o%e%t #o$ desi&%i%& a))$o)$iate o%#!i t ma%a&eme%t s"stems, o%#!i t t$ai%i%&s #o$ sta##, a%d ADR i%te$(e%tio%s-

A se o%d i%sti&atio% #o$ this thesis 'as m" i%te$est i% o%#!i t $eso!utio% t$ai%i%& #o$ hea!th )$o#essio%a!s- I am )a$ti u!a$!" i%te$ested i% the )ote%tia! #o$ )$a ti i%& !i%i ia%s 'ho $e ei(e t$ai%i%& a%d me%to$i%& i% o%#!i t ma%a&eme%t to he!) mai%st$eam o%#!i t ma%a&eme%t s4i!!s a%d )$o esses 'ithi% the hea!th a$e )$o#essio%sTo'a$ds this e%d, m" se o%d &oa! #o$ the thesis 'as to !a$i#" 'he$e the #ie!d u$$e%t!" sta%ds i% $e!atio% to edu atio% a%d t$ai%i%& o))o$tu%ities #o$ !i%i a!!"6)$a ti i%& hea!th a$e )$o#essio%a!s-

This $esea$ h aims to se$(e #i(e )u$)oses:

1. Assist )$a titio%e$s b" ma))i%& the o%#!i ts a%d $es)o%ses to o%#!i t i% hea!th a$e2.
+e&i% om)a$iso%s that ma" a!!o' the i%dust$" to de(e!o) best6)$a ti e i%di ato$s o# su ess-

3. He!) hos)ita!s as the" estab!ish %e' o%#!i t ma%a&eme%t s"stems i% $es)o%se to the
233? /oi%t Commissio% o% A $editatio% o# Hea!th a$e O$&a%i5atio%s sta%da$ds-

4.

He!) de(e!o) a))$o)$iate t$ai%i%& #o$ hea!th a$e )$o#essio%a!s o% o%#!i t ma%a&eme%t i% hea!th a$e-

5. Ide%ti#" u) omi%& t$e%ds i% the #ie!d-

"ESEA"CH #ESI$!

The $esea$ h 'as desi&%ed so that the bu!4 o# the i%#o$matio% used i% the thesis 'as obtai%ed th$ou&h $e(ie's o# the )ub!ished !ite$atu$e o% the #ie!d a%d )ub!i !"6a(ai!ab!e do ume%ts des $ibi%& the mo$e i%%o(ati(e dis)ute $eso!utio% )$o&$ams-

The $esea$ h )$oto o! 'as de(e!o)ed 'ith the &oa! o# o%du ti%& semi6st$u tu$ed i%te$(ie's 'ith 1603 e8)e$ts i% the #ie!d o# hea!th a$e dis)ute $eso!utio%-

Te% subDe ts 'e$e #o$ma!!" i%te$(ie'ed as )a$t o# the $esea$ h, ide%ti#ied th$ou&h a ombi%atio% o# )u$)osi(e sam)!i%&, s%o'ba!! sam)!i%&, a%d o%(e%ie% e sam)!i%&- The i%te$(ie's 'e$e !a$&e!" o%du ted (ia te!e)ho%e a%d i% )e$so%, 'ith o%e i%te$(ie' o%du ted (ia emai!-

Pu$)osi(e sam)!i%& ide%ti#ied #i(e o# the #i%a! i%te$(ie'ees- I% !i%e 'ith the i%itia! $esea$ h )$oto o! #o$ )u$)osi(e sam)!i%&, a !ist o# )ote%tia! i%te$(ie'ees 'as om)i!ed o# estab!ished e8)e$ts 'ithi% the hea!th a$e dis)ute $eso!utio% #ie!d 'ho had )ub!ished a ademi a$ti !es o$ boo4s o% this to)i i% the )ast- Re*uests #o$ i%te$(ie's 'e$e e8te%ded to te% i%di(idua!s o% this !ist, 'ith #i(e u!timate!" )a$ti i)ati%&-

I% a de(iatio% #$om the o$i&i%a! $esea$ h desi&%, th$ee i%te$(ie's 'e$e o%du ted 'ith hea!th a$e )$o(ide$s ide%ti#ied th$ou&h o%(e%ie% e sam)!i%& Ee8isti%& o%ta ts o# the autho$ 'ho 'e$e 4%o'!ed&eab!e o# hea!th a$e o%#!i t d"%ami s but had %ot )ub!ished i% the !ite$atu$eF- The" 'e$e se!e ted to )$o(ide mo$e ba!a% e to the i%te$(ie'ee )oo!, as $e!ati(e!" #e' )$a ti i%& !i%i ia%s ha(e bee% a ti(e!" )ub!ishi%& i% the !ite$atu$e a%dGo$ 'e$e a(ai!ab!e #o$ i%te$(ie's-

These th$ee i%te$(ie's 'ith the %o%6)ub!ishi%& hea!th a$e )$o(ide$s a essed (a!uab!e )e$s)e ti(es a%d $esu!ted i% additio%a! i%te$(ie's 'ith %o%6)ub!ishi%& !i%i ia%s a ti(e i% hea!th a$e dis)ute $eso!utio% 'ho

'ou!d %ot ha(e bee%

o%ta ted th$ou&h the )u$)osi(e sam)!i%&- I% #utu$e $esea$ h, the

)u$)osi(e sam)!i%& desi&% shou!d be $e(ised to i% !ude mo$e di(e$sit" i% the i%te$(ie'ee )oo!, s)e i#i a!!" ta$&eti%& !i%i a!!"6)$a ti i%& hea!th a$e )$o(ide$s %ot ide%ti#ied th$ou&h the !ite$atu$e-

The $emai%i%& i%te$(ie's 'e$e o%du ted 'ith i%di(idua!s ide%ti#ied th$ou&h s%o'ba!! sam)!i%& a$isi%& #$om the i%itia! $ou%d o# i%te$(ie's-

No%e o# the i%te$(ie's 'e$e di&ita!!" $e o$ded- Notes 'e$e ta4e% 'ith summa$" ta4e6a'a" )oi%ts $e)eated to the i%te$(ie'ee at the e%d o# the o%(e$satio%, i# desi$ed b" the i%te$(ie'ee-

A semi6st$u tu$ed i%te$(ie' #o$mat 'as #o!!o'ed #o$ a!! i%te$(ie's- The )$e!imi%a$" o$e o# *uestio%s e%te$ed o% these t'o issues:

1 HHo' do 'e 4%o' that dis)ute $eso!utio% )$a ti es a$e (a!uab!e a%d %e essa$" i%
US hos)ita! setti%&sIH

2 B.hat o%stitutes su ess#u! o%#!i t ma%a&eme%t i% US hos)ita! setti%&sIC

The *uestio%s e(o!(ed th$ou&hout the ou$se o# i%te$(ie's, &$o'i%& mo$e s)e i#i at !ate$ sta&es 'ith si&%i#i a%t ada)tatio% o# the *uestio%s to mat h the s)e i#i as)e t o# hea!th a$e dis)ute $eso!utio% a))!i ab!e to the i%te$(ie'ee-

I%te$(ie'ees 'e$e o##e$ed the o)tio% to $e*uest #u!! a%o%"mit", )a$tia! a%o%"mit", o$ #u!! dis !osu$e about thei$ )a$ti i)atio% i% the i%te$(ie'- No i%te$(ie'ee $e*uested #u!! a%o%"mit" #o$ the e%ti$e i%te$(ie', a!thou&h some $e*uested that e$tai% i%stitutio%a! %ames be omitted a%d some omme%ts %ot be att$ibuted- Some i%te$(ie'ees $e*uested att$ibutio% #o$ thei$ omme%ts-

This $esea$ h methodo!o&" o# a !ite$atu$e su$(e" su))!eme%ted 'ith semi6st$u tu$ed i%te$(ie's 'as hose% as a om)$omise bet'ee% the %eed to su$(e" the #ie!d as it u$$e%t!" sta%ds a%d the desi$e to ide%ti#" &e%e$a! u) omi%& t$e%ds that ha(e "et to eme$&e i% the !ite$atu$e- The si5e o# the i%te$(ie' )oo! a%d the s o)e o# the $esea$ h *uestio%s 'e$e di tated b" the time#$ame a(ai!ab!e to om)!ete this maste$9s thesis-

Je" assum)tio%s u%de$!"i%& the $esea$ h a$e that o%#!i t e8ists i% hea!th a$e7 that i%te%tio%a! ma%a&eme%t o# this o%#!i t is )ossib!e7 a%d that the$e is (a!ue i% attem)ti%& to ma%a&e this o%#!i tThe su$(e" o# the !ite$atu$e is based o% the )$emise that this !ite$atu$e is su##i ie%t!" b$oad to )$o(ide a #ai$!" om)$ehe%si(e ma) o# the t")es o# o%#!i t i% hea!th a$e, a%d that the )ub!ished 'o$4 a u$ate!" $e#!e ts o%#!i t as e8)e$ie% ed b" hea!th a$e sta4eho!de$s i% hea!th a$e e%(i$o%me%ts- Assum)tio%s i% uti!i5i%& semi6st$u tu$ed i%te$(ie's a$e that )ub!ished o%#!i t ma%a&eme%t )$a titio%e$s u%de$sta%d eme$&i%& t$e%ds i% the #ie!d a%d that thei$ )e$s)e ti(es a$e at !east some'hat $e)$ese%tati(e o# the b$oade$ hea!th a$e o%#!i t ma%a&eme%t #ie!d-

This $esea$ h is !imited b" its sma!! su$(e" si5e a%d its #o us so!e!" o% US hea!th a$e o%#!i t ma%a&eme%t-

CO! LICT I! HEALTHCA"E

%&at is meant '( t&e term )conflict*+

This )a)e$ de#i%es conflict as a $ea! o$ a))a$e%t i% om)atibi!it" o# )a$ties9 %eeds o$ i%te$ests-C0 This )ositio%s o%#!i t as a mo$e e8)a%si(e te$m tha% dispute, 'hi h t$aditio%a!!" is asso iated mo$e !ose!" 'ith !e&a! !aims a%d mo$e #o$ma! e8)$essio%s o# o%#!i t-2 This b$oad de#i%itio% o# o%#!i t a ommodates both

!ate%t a%d ma%i#est #o$ms o# o%#!i t- .hi!e this o% e)tua!i5es o%#!i t as a $e!atio%a! )he%ome%o% i%(o!(i%& the i%te$a tio%s a%d $e!atio%s bet'ee% t'o o$ mo$e )a$ties, it a e)ts that o%#!i t a% e8ist 'he%

o%!" o%e )a$t" )e$ ei(es the$e to be o%#!i t- Co%#!i t a% i%(o!(e u%$eso!(ed )$ob!ems #$om )ast i%te$a tio%s, st$u&&!es #o$ )o'e$, the 'a"s )a$ties ta!4 'ith ea h othe$, a%d the 'a"s de isio%s a$e made-;

Ma%i#estatio%s o# o%#!i t #a!! o% a s)e t$um #$om disa&$eeme%ts to (io!e% e- Di##e$e%tiatio% o# o%#!i ts is t")i a!!" e8)$essed a o$di%& to se(e$it" o# im)a t a%d i%te%sit" o# o%#!i t-

#oes conflict exist in &ealt&care+

Co%#!i t is 'ides)$ead i% hea!th a$e-= .hi!e the o%#!i t is $a$e!" (io!e%t, it e8ists o% a (a$iet" o# !e(e!s 'ith di##e$i%& de&$ees o# i%te%sit"- Hea!th a$e o%#!i t ommo%!" o u$s bet'ee% )atie%ts a%d )$o(ide$s,

)atie%ts a%d )a"e$s, )$o(ide$s 'ith thei$ o!!ea&ues, a%d )$o(ide$s 'ith hea!th a$e admi%ist$ato$s-

Robe$t A- +ush a%d /ose)h P- Fo!&e$, The Promise of Mediation ESa% F$a% is o: /osse"6+ass, 0??=F, 1<-

2 Ed'a$d Daue$, BPosts $i)t o% Hea!th Ca$e Dis)ute Reso!utio%: Co%#!i t Ma%a&eme%t a%d the Ro!e o# Cu!tu$e,C Georgia State University Law Review, 20, %o- = ESumme$ 2331F: 032?6031=3 M"$a .a$$e% Ise%ha$t a%d Mi hae! S)a%&!e, Collaborative Conflict EThousa%d Oa4s, CA: Sa&e Pub!i atio%s, 2333F, 2pproaches to Resolving

4 Fo$ a% e8te%si(e !ist o# o%#!i t issues, see Ame$i a% Hea!th La'"e$s Asso iatio%, Conflict Management Tool!it E233?F, htt):GG'''-hea!th!a'"e$s-o$&GResou$ esGADRGPa&esGADRToo!4it-as)8 Ea essed 2? Ma" 2303F, 0=601-

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Hea!th a$e )$o(ide$s themse!(es ide%ti#" hi&h !e(e!s o# o%#!i t i% the 'o$4)!a e- The Ame$i a% Co!!e&e o# Ph"si ia% E8e uti(es9 233? Do to$ > Nu$se +eha(io$ Su$(e" #ou%d that ?AK o# those su$(e"ed had 'it%essed a% i% ide%t o# dis$u)ti(e beha(io$ bet'ee% %u$ses a%d )h"si ia%s i% the !ast "ea$, 'ith ;3K o# )a$ti i)a%ts $e)o$ti%& seei%& i% ide%ts 'ee4!" a%d 03K dai!"- 1

I% a 233= stud" b" A%de$so% a%d D9A%to%io, hea!th )$o#essio%a!s i%di ated thei$ )e$ e)tio% that 13K o# a )h"si ia%9s time is s)e%t i% o%#!i t-< <2K o# the o%#!i t e8)e$ie% ed 'as 'ith othe$ hea!th )$o#essio%a!s-

A% i%te$%atio%a! su$(e" o# ICU a$e )$o(ide$s )ub!ished i% 233? $e)o$ted that @0K o# the @=?A )a$ti i)a%ts su$(e"ed )e$ ei(ed o%#!i t i% the ICU 'ithi% the )$e(ious 'ee4- @ A3K o# the o%#!i ts 'e$e see% as doi%& mo$e ha$m tha% &ood, a%d o(e$ 13K o# the o%#!i ts 'e$e des $ibed as Bse(e$e-C Nu$se>)h"si ia% o%#!i ts 'e$e the most ommo% E;2-<KF, #o!!o'ed b" o%#!i ts amo%& %u$ses E2@-;KF a%d sta##6$e!ati(e o%#!i ts E2<-<KF-

A stud" b" Studde$t, et a!-, o# )atie%ts 'ith a )$o!o%&ed sta" i% the ICU #ou%d that o(e$ ;3K o# )atie%ts had o%#!i t asso iated 'ith thei$ a$e- A 1@K o# these o%#!i ts 'e$e team6#ami!"

dis)utes, ;0K 'e$e i%t$a6team dis)utes, a%d 02K o

u$$ed amo%& #ami!" membe$s-

%&at fuels conflict in &ealt&care+

5 Ca$$ie /oh%so%, B+ad +!ood: Do to$ > Nu$se +eha(io$ P$ob!ems Im)a t Patie%t Ca$e,C Physician "#ecutive $ournal of Medical Management ENo(embe$GDe embe$ 233?F: <600htt):GG'''-oh%u$ses-o$&GCo%te%tGNa(i&atio%Me%uGResou$ esG.o$4)!a eLio!e% eRe)o$ti%&Fo$mG/oh%so% MCa$$ieM0-)d# Ea essed 2A Ma" 2303F6 Co!b" A%de$so% a%d Li%da D9A%to%io, BEm)i$i a! I%si&hts: U%de$sta%di%& the U%i*ue Cu!tu$e o# Hea!th Ca$e Co%#!i t,C %ispute Resolution Maga&ine EFa!! 233=F: 01,0<t")es, sou$ es, a%d )$edi to$s,C 'ntensive Care Medicine 2? E233;F:0=A?>0=?@-

7 E- A5ou!e" et a!-, BP$e(a!e% e a%d Fa to$s i% I%te%si(e Ca$e U%it Co%#!i ts The Co%#!i us Stud",C merican $ournal of Respiratory and Critical Care Medicine 0A3 E233?F: A1;A<38 D-M- Studde$t, et a!-, BCo%#!i t i% the a$e o# )atie%ts 'ith )$o!o%&ed sta" i% the ICU:

Ma%" #a to$s o%t$ibute to hea!th a$e o%#!i t- Ch$o%i time )$essu$es ombi%e 'ith $esou$ e a%d em)!o"ee sho$ta&es to $eate ommu%i atio% ha!!e%&es a%d )!a e ma%" )$o(ide$s i% ad(e$sa$ia! )ositio%s-?
Cha!!e%&es ba!a% i%& ost (s- *ua!it" )$essu$es, bud&et uts, )$o(ide$ sho$ta&es, a%d shi#ti%& e8)e tatio%s $eate o%ditio%s $i)e #o$ o%#!i t03

Ma$4et )$essu$es, shi#ti%& #i%a% ia! $is4s, misa!i&%ed i% e%ti(es, bioethi a!

ha!!e%&es, o(e$bu$de%ed 'o$4!oads a%d #ati&ue, a%d om)!e8 eme$&i%& te h%o!o&ies )!a e additio%a! st$ess o% hea!th a$e )$o(ide$s- The om)!e8it" a%d (o!ume o# $e&u!atio%s add #$ust$atio% a%d )$essu$es to ma%" hea!th a$e )$o(ide$s, !eadi%& to a%&e$ e8)$essed i% u%)$o#essio%a! beha(io$-

These )$essu$es o!!ide 'ith the e8)a%di%& dema%d #o$ se$(i es, i% $easi%& $e&u!atio%, a%d hi&he$ e8)e tatio%s #o$ t$a%s)a$e% ", a ou%tabi!it" a%d *ua!it" o# a$e out omes- Hea!th a$e )$o(ide$s a$e au&ht i% the midd!e-00 The ha%&i%& !a%ds a)e o# hea!th a$e is !i4e!" to i% $easi%&!" a!te$ s"stems a%d $o!es, setti%& the sta&e #o$ #u$the$ o%#!i t-

Mo$eo(e$, t$aditio%a!!" $i&id )$o#essio%a! hie$a$ hies 'ith st$o%& )o'e$ imba!a% es a% )e$)etuate si!e% e, u%i!ate$a! de isio%6ma4i%& a%d i%e##e ti(e a))$oa hes to o%#!i t- Resea$ h su&&ests that hea!th a$e 'o$4e$s te%d to eithe$ a(oid ma%a&i%& o%#!i t o$ be om)etiti(e, both o# 'hi h a% e8a e$bate o%#!i ts-02

De $eased !e(e!s o# t$ust bet'ee% )atie%ts, !i%i ia%s, admi%ist$atio%, )a"e$s, a%d o$&a%i5atio%s #u$the$ st$ai% a!! $e!atio%shi)s a%d #a i!itate o%#!i t-

%&at are t&e costs of conflict+

9 Li$&i%ia Mo$$iso%, B(eyo!a) The Shi#ti%& Sha)e o# Dis)ute Reso!utio% i% Hea!th Ca$e,C Georgia State University Law Review 20, %o- = ESumme$ 2331F: ?;0Deb$a Ge$a$di, Conflict "ngagement Training for (ealth Professionals) Recommendations for Creating Conflict Competent *rgani&ations+ ,hile Paper for (ealthcare and %ispute Resolution ProfessionalsEHa!# Moo% +a", CA: EHCCO, 2303F, )ub!ished o%!i%e at '''-eh o- om Ea essed 01 Ma" 2303F- 02 Deb$a Ge$a$di, BThe Cu!tu$e o# Hea!th a$e: Ho' P$o#essio%a! a%d O$&a%i5atio%a! Cu!tu$es Im)a t Co%#!i t Ma%a&eme%t,C Georgia State University Law Review 20, %o- = ESumme$ 2331F: A1@6A?3-

10 Je%%eth Coh% a%d Mi hae! Peet5, BSu$&eo% F$ust$atio%: Co%tem)o$a$" P$ob!ems, P$a ti a! So!utio%s,C Contemporary Surgery 1?, %o- 2, EFeb 233;F: @<6A100

The data su&&esti%& that 13K o# )h"si ia%s9 time is s)e%t i% o%#!i t, 'ith simi!a$ time bu$de%s )!a ed o%

%u$ses a%d e8e uti(es, a$$ies e%o$mous #i%a% ia! a%d e##i ie% " im)!i atio%s #o$ hea!th a$e o$&a%i5atio%s-0;

The /oi%t Commissio% /u!" 233A Se%ti%e! E(e%t A!e$t N=3 ites e(ide% e o# o$$e!atio%s bet'ee%
u%)$o#essio%a! Edis$u)ti(e a%d i%timidati%&F beha(io$ a%d the i% ide% e o# ad(e$se e(e%ts a%d medi a!

e$$o$s, )atie%t satis#a tio%, osts o# a$e, a%d sta## $ete%tio%-

Ge$a$di )$o(ides the #o!!o'i%& tab!e !isti%& osts o# u%ma%a&ed o%#!i t: 0= Tab!e 0- Costs o# Co%#!i t %irect Costs of Conflict
'ndirect Costs of Conflict Team mo$a!e, moti(atio%

Liti&atio% osts: atto$%e"9s #ees, e8)e$t #o$ o$&a%i5atio%a! testimo%", de)ositio%s, !ost 'o$4 time, ha%&e, 'o$4)!a e t$a%s $i)ts, do ume%t )$odu tio%, et $e!atio%shi)s dama&ed, Ma%a&eme%t )$odu ti(it": time s)e%t 'o$4i%& o% $eso!(i%& o%#!i ts $athe$ tha% othe$ ma%a&e$ia! duties Tu$%o(e$ osts #o$ t$ai%i%& %e' sta##, $e $uitme%t osts
!ead to #utu$e o%#!i ts

u%$eso!(ed te%sio%s that

t$aditio%a! !iti&atio% a% !ead to mo$e ost!" out!a"s #o$ hea!th a$e tha% i# o%#!i ts a$e add$essed ea$!" a%d di$e t!"
Cost to $e)utatio% o# o$&a%i5atio% a%d o# a$e )$o#essio%a!7 %e&ati(e )ub!i it"Gmedia o(e$a&e

Disabi!it"Gst$ess !aims, 'o$4ma%9s om)e%satio% !aims Re&u!ato$" #i%es #o$ %o% om)!ia% e o$ !oss o# o%t$a ts o$ )$o(ide$ status 'ith i%su$e$s a%d Medi a$eGMedi aid

Lost o))o$tu%ities #o$ )u$sui%& a)ita! )u$ hases, e8)a%di%& se$(i es, e%ha% i%& ustome$ satis#a tio% )$o&$ams, de(e!o)i%& sta##G!eade$s Costs to )atie%ts due to de!a"s i%

Loss o# st$ate&i ma$4et )ositio%i%& due to )ub!i dis !osu$e o# i%#o$matio% $e&a$di%& the dis)uteGbad )ub!i $e!atio%s

13 See Co!b" A%de$so% a%d Li%da D9A%to%io, BEm)i$i a! I%si&hts: U%de$sta%di%& the U%i*ue Cu!tu$e o# Hea!th Ca$e

Co%#!i t,C %ispute Resolution Maga&ineEFa!! 233=F: 01,0<-

14 Deb$a Ge$a$di, BUsi%&

?

Mediatio% dvanced Practice in cute and Te h%i*ues to Critical Care 01, %o- 2 E233=F, 0A=7 Ma%a&e see a!so Ge$a$di, Conflict Co%#!i t a%d "ngagement Training for (ealth C$eate Hea!th" Professionals- ;7 Ph"!!is +e 4 J$ite4, .o$4 BThe OCosts9 o# Co%#!i t: A% E%(i$o%me%ts,C O$&a%i5atio%a! I%(e%to$",C a essed C. Clinical 01 Ma" 2303 at 'ssues) htt):GG'''-)h"!!is4$ite4- omG-

%irect Costs of Conflict Costs asso iated 'ith i% $eased a$e e8)e%ditu$es #o$ )atie%ts 'ith )$e(e%tab!e )oo$ o$ ad(e$se out omes Sabota&e, the#t, dama&e to #a i!ities

'ndirect Costs of Conflict I% $eased i% ide% e o# dis$u)ti(e beha(io$ b" sta## a%d medi a! )$o#essio%a!s Emotio%a! osts: )ai%, tu$moi! #o$ those i%(o!(ed i% the o%#!i t

%&( is understanding conflict important in &ealt&care+

Co%#!i t is a #u%dame%ta! as)e t o# hea!th a$e a%d its )$ese% e a##e ts a!! those asso iated 'ith hea!th a$e- The hi&h )$e(a!e% e a%d osts o# o%#!i t i% $easi%&!" #o$ e sta4eho!de$s to o%#$o%t o%#!i ts that 'e$e i&%o$ed i% the )ast- I% $easi%&!", satis#a to$" )e$#o$ma% e o# Dob duties $e*ui$es su ess#u! e%&a&eme%t 'ith o%#!i t-

Risi%& e8)e tatio%s that )$o(ide$s a%d s"stems do mo$e 'ith !ess i% $ease )$essu$es o% hea!th a$e )$o(ide$s a%d #o$ e them to ma%a&e o%#!i ti%& &oa!s- The i% $easi%& om)!e8it" o# hea!th a$e e%(i$o%me%ts %e essitates mo$e e##e ti(e ommu%i atio% a%d Doi%t )$ob!em so!(i%& 'ithi% )$o(ide$ teams- P$a titio%e$s a$e a!!ed to o!!abo$ate bette$ i% mu!tidis i)!i%a$" )atie%t a$e teams, hos)ita! ommittees, )ub!i hea!th issues, tea hi%&, a%d $esea$ h- 01 Ad(a% i%& )$o(ide$s9 o%#!i t e%&a&eme%t s4i!!s is $e*ui$ed to su ess#u!!" meet these e8)e tatio%s-

Additio%a!!", hea!th a$e o%sume$s i% $easi%&!" e8)e t &ood ommu%i atio%, bette$ i%#o$matio% e8 ha%&e, a%d !ess hie$a$ hi a! i%te$a tio%s #$om thei$ hea!th a$e )$o(ide$s- This t$e%d, a!o%& 'ith i% $easi%& o% e$%s o(e$ ost a%d the e8)e tatio% that both hea!th a$e )$o(ide$s a%d )atie%ts be ome i% $easi%&!" o%s ious o# the ost o# thei$ hea!th a$e de isio%s, )ush the )$o(ide$ > )atie%t $e!atio%shi) to'a$ds sha$ed de isio%6ma4i%& mode!s that $e*ui$e %e' s4i!!s a%d #$ame'o$4s #o$ )$o(ide$ > )atie%t i%te$a tio%s-

01

E!!e% P'eibe!, et a!-, B.hat Sti 4s: Ho' Medi a! Reside%ts a%d A ademi Hea!th Ca$e Fa u!t" T$a%s#e$ Co%#!i t Reso!utio% T$ai%i%& #$om the .o$4sho) to the .o$4)!a e,C Conflict Resolution /uarterly 21, %o- ; ES)$i%& 233AF: ;22-

03

The$e is a% ethi a! )ush to'a$ds a)o!o&" a%d #u!! dis !osu$e i% ma%" hea!th a$e u!tu$es, 'ith a

$editatio%

sta%da$ds a%d !e&is!atio% a!so i%(o!(ed- Ad(e$se e(e%t dis !osu$e )$oto o!s a$e %o' sta%da$d 'ithi% ma%" hea!th a$e o$&a%i5atio%s a%d i%su$a% e om)a%ies- I% $easi%&!" !e&is!atio% is ma%dati%& dis !osu$e-

I% /a%ua$" 233? the /oi%t Commissio% o% A

$editatio% o# Hea!th a$e O$&a%i5atio%s sta%da$ds o% e$%i%& $editatio%

o%#!i t ma%a&eme%t 'e%t i%to e##e t, 'ith di$e t im)!i atio%s #o$ hos)ita!s %atio%a!!"- These a

sta%da$ds $e*ui$e that: 0F BThe &o(e$%i%& bod" )$o(ides a s"stem #o$ $eso!(i%& o%#!i ts amo%& i%di(idua!s 'o$4i%& i% the hos)ita!C7 2F BThe Qo$&a%i5atio%R ma%a&es o%#!i ts bet'ee% !eade$shi) &$ou)s to )$ote t the *ua!it" a%d sa#et" o# a$eC7 a%d ;F BLeade$s $eate a%d mai%tai% a u!tu$e o# sa#et" a%d *ua!it" th$ou&hout the o$&a%i5atio%,C i% !udi%& a )$o ess #o$ ma%a&i%& dis$u)ti(e a%d i%a))$o)$iate beha(io$s-0< These sta%da$ds )ush o$&a%i5atio%s to #u$the$ de(e!o) o%#!i t ma%a&eme%t )o!i ies a%d s"stems, b$i%&i%& mo$e hea!th a$e sta4eho!de$s i%to o%ta t 'ith the #ie!d- 0@

Categori,ation of Healt&care Conflict #(namics

This )a)e$ o$&a%i5es hea!th a$e o%#!i ts i%to #ou$ maDo$ d"%ami s based o% the )a$ties i%(o!(ed 'ith the o%#!i t: )$o(ide$ > )$o(ide$7 )atie%t > )$o(ide$7 )atie%t > )a"e$7 a%d )$o(ide$ > admi%ist$atio%-0A A%

16 Suotatio%s #$om: 0F Sta%da$d LD-30-3;-307 2F Sta%da$d LD-32-3=-307 ;F Sta%da$d LD-3;-30-30 a%d E!eme%ts o# Pe$#o$ma% e #o$ LD-3;-30-30, $es)e ti(e!"- /oi%t Commissio% Resou$ es, The $oint Commission ccreditation Standards for (ospitals EOa4b$oo4 Te$$a e, IL: /oi%t Commissio% o% A $editatio% o# Hea!th a$e O$&a%i5atio%, 233?Fhtt):GG'''-hea!th!a'"e$s-o$&GResou$ esGADRGPa&esGADRToo!4it-as)8 Ea
0A

17

Ame$i a% Hea!th La'"e$s Asso iatio%, Conflict Management Tool!it E233?F,

essed 2? Ma" 2303F-

The$e a$e %ume$ous additio%a!, mo$e s)e i#i ate&o$ies o# $e!atio%shi)s that ou!d be de#i%ed, "et 'he% i%te$)$eted b$oad!" these #ou$ d"%ami s a)tu$e most dis)utes- P$o(ide$ is u%de$stood to i% !ude %ot o%!" %u$ses a%d )h"si ia%s but a!so )h"si ia%9s assista%ts, %u$se )$a titio%e$s, so ia! 'o$4e$s, !abo$ato$" sta##, $adio!o&" sta##, )ha$ma ists, )h"si a! the$a)ists, a%d othe$s i%(o!(ed 'ith )atie%t a$e- I% this t")o!o&", do to$6i%su$a% e a%d do to$6$is4 ma%a&eme%t o%#!i ts #a!! u%de$ the d"%ami o# )$o(ide$6admi%ist$atio% o%#!i ts- Do to$6#ami!" o%#!i ts a$e simi!a$!" &$ou)ed u%de$ )$o(ide$6)atie%t o%#!i ts- Fo$ a!te$%ati(e 'a"s o# ate&o$i5i%& these $e!atio%shi)s, see A%de$so% a%d D9A%to%io, BEm)i$i a! I%si&hts,C 0160@-

00

a!te$%ati(e a))$oa h is to ate&o$i5e o%#!i ts based o% t")e o# dis)ute- This ou!d be a usi%& the #o!!o'i%& #i(e maDo$ t")es o# o%#!i ts a%d thei$ auses su&&ested b" Moo$e:
0?

om)!ished

1 Relationship conflicts, aused b": st$o%& emotio%s7 mis)e$ e)tio%s o$ ste$eot")es7

)oo$ ommu%i atio% o$ mis ommu%i atio%7 $e)etiti(e %e&ati(e beha(io$- Re!atio%shi) o%#!i ts a$e )$ese%t i% most i%sta% es o# hea!th a$e o%#!i t, i% a!! #ou$ d"%ami s-

2 0alue conflicts, aused b": di##e$e% e $ite$ia #o$ e(a!uati%& ideas o$ beha(io$7 e8 !usi(e
i%t$i%si a!!" (a!uab!e &oa!s7 di##e$e%t 'a"s o# !i#e, ideo!o&" o$ $e!i&io%- La!ue o%#!i ts a$e %otab!e i% e%d6o#6!i#e de isio%s i%(o!(i%& )atie%ts, thei$ #ami!ies, a%d )$o(ide$, but a!so a))ea$ i% some )$o(ide$ > admi%ist$ato$ o%#!i ts-

3 Structural conflicts, aused b": dest$u ti(e )atte$%s o# beha(io$ o$ i%te$a tio%7 u%e*ua!
o%t$o!, o'%e$shi), o$ dist$ibutio% o# $esou$ es7 u%e*ua! )o'e$ a%d autho$it"7 &eo&$a)hi a!, )h"si a!, o$ e%(i$o%me%ta! #a to$s that hi%de$ oo)e$atio%7 time o%st$ai%ts- St$u tu$a! o%#!i ts a$e )$omi%e%t i% )$o(ide$ > )$o(ide$ dis)utes-

'nterest conflicts,

aused b": )e$ ei(ed o$ a tua!

om)etitio% o(e$ substa%ti(e E o%te%tF issues7

)$o edu$a! i%te$ests7 )s" ho!o&i a! i%te$ests- I%te$est o%#!i ts a$e #ou%d i% ea h d"%ami -

5 %ata conflicts, aused b": !a 4 o# i%#o$matio%7 misi%#o$matio%7 di##e$e%t (ie's o% 'hat is

$e!e(a%t7 di##e$e%t i%te$)$etatio%s o# data7 di##e$e%t assessme%ts )$o edu$es- Data o%#!i ts a$e a!so #ou%d i% ea h d"%ami -

I ate&o$i5e the o%#!i ts b" a to$s $athe$ tha% t")e be ause the o%te8ts, u!tu$es, )o'e$ d"%ami s, )$essu$es, a%d a))$oa hes to o%#!i t (a$" mo$e a $oss a to$s tha% the" do a $oss t")es o# o%#!i t- Fo$ hea!th a$e o%#!i t ma%a&eme%t s"stems, the a to$s i%(o!(ed 'ith the o%#!i t a$e mo$e si&%i#i a%t (a$iab!es tha% the t")es o# o%#!i ts i%(o!(ed- Cate&o$i5i%& b" a to$ bette$ hi&h!i&hts the o$e $e!atio%shi)s i%(o!(ed 'ith ea h d"%ami a%d is mo$e use#u! #o$ o%#!i t a%a!"sis, t$ai%i%&, a%d o(e$a!! s"stem desi&%- I# desi$ed, ha(i%& #i$st disti%&uished the a to$s i%(o!(ed 'ith the d"%ami , #u$the$ disa&&$e&atio% o# o%#!i ts

0?

Ch$isto)he$ Moo$e, The Mediation Process- 1rd ed+ ESa% F$a% is o: /osse"6+ass, 233;F, <=-

02

b" t")e a% be used as a se o%da$" too! to )i%)oi%t )$ob!ems, st$e%&the% o%#!i t ma%a&eme%t s"stems, a%d

tai!o$ i%te$(e%tio%s s)e i#i to a ase-

0;

CO! LICT MA!A$EME!T I! HEALTHCA"E

#efinitions

The thesis uti!i5es the te$m conflict management i% the b$oadest se%se as the &e%e$i te$m to o(e$ the e%ti$e $a%&e o# )ositi(e o%#!i t ha%d!i%&- 23

The$e $emai% %o sta%da$di5ed de#i%itio%s o# o%#!i t ma%a&eme%t, o%#!i t $eso!utio%, o%#!i t e%&a&eme%t, o$ dis)ute $eso!utio%- Des)ite e##o$ts b" i%di(idua! autho$s to di##e$e%tiate these i%to disti% t o% e)ts, the te$ms a$e sti!! !a$&e!" used i%te$ ha%&eab!"- Fu$the$, the de#i%itio%s o# a%d disti% tio%s i% these te$ms made b" e$tai% autho$s o#te% o%!" a))!" to a )a$ti u!a$ domai% o# o%#!i t E'o$4)!a e o%#!i t, i%te$%atio%a! o%#!i t, e%(i$o%me%ta! o%#!i t, et -F o$ a )a$ti u!a$ a ademi o$ )$o#essio%a! #ie!d E!a', so io!o&", i%te$%atio%a! $e!atio%s, ma%a&eme%t, et -F-

.hi!e the disti% tio%s bet'ee% these de#i%itio%s a% be im)o$ta%t i% e$tai% domai%s, i% the o%te8t o# hea!th a$e o%#!i ts the di##e$e%t te$ms t")i a!!" do %ot a$$" disti% t theo$eti a! o$ie%tatio%s- The s"stems a%d i%te$(e%tio%s )ut i% )!a e to e%&a&e 'ith hea!th a$e o%#!i ts a$e $a$e!" dete$mi%ed b" the te$m used to !abe! that s"stem o$ i%te$(e%tio%- It is !a$&e!" the s"stem a%d its )$a titio%e$s that de#i%e the theo$eti a! o$ie%tatio%, %ot the !abe!-

Thus, 'hi!e a 4%o'!ed&i%& the )ote%tia! that hea!th a$e o%#!i t te$mi%o!o&" ma" i% $easi%&!" o$$e!ate 'ith disti% t theo$eti a! o$ie%tatio%s i% the #utu$e, this thesis uses these te$ms i%te$ ha%&eab!"- As o%#!i t ma%a&eme%t is u$$e%t!" the te$m most 'ide!" used to des $ibe s"stemati a))$oa hes to $es)o%di%& to hea!th a$e o%#!i t, that is the )$ima$" te$m ado)ted he$e-

23

Fo$ #u$the$ $e#e$e% es to de#i%itio%s, see O!i(e$ Ramsbotham, Tom .oodhouse, a%d Hu&h Mia!!,

Contemporary Conflict Resolution- 2nd ed+ EMa!de%, MA: Po!it" P$ess, 2331F, 2?-

0=

O%e eme$&i%& t$e%d i% te$mi%o!o&" 'o$th %oti%& is the )ossibi!it" that conflict engagement 'i!! be ome the )$e#e$$ed meta6te$m i% the hea!th a$e #ie!d to $e#e$ to the B a)a it" to e##e ti(e!" e%te$ i%to a%d add$ess o%#!i ts o# (a$ious t")es, at (a$ious de)ths, a%d o(e$ di##e$i%& time #$ames, $a%&i%& #$om sho$t6!i(ed i%te$a tio%s to mo$e om)!e8 a%d )$ot$a ted dis)utes-C 20

%&at does conflict management in &ealt&care mean+

Co%#!i t ma%a&eme%t i% hea!th a$e $e#e$s to s"stems, $es)o%se #$ame'o$4s, )$o esses, s4i!!s, a%d i%te$(e%tio%s #o$ e%&a&i%& 'ith hea!th a$e o%#!i t- The #ie!d d$a's #$om $esea$ h a%d )$a ti e i%(o!(i%& o%#!i t $eso!utio% theo$"7 'o$4)!a e o%#!i t ma%a&eme%t s"stems7 o%#!i t ma%a&eme%t s4i!!s, )$o esses, a%d te h%i*ues7 a%d o%#!i t $eso!utio% t$ai%i%&-

Ge$a$di su&&ests some o# the o$e om)ete% ies #o$ su ess#u! o%#!i t e%&a&eme%t i% hea!th a$e: 22

o%#!i t a%a!"sis

2 $e#!e ti(e )$a ti e 3 %e&otiatio% 4

ommu%i atio% s4i!!s E!iste%i%&G a 4%o'!ed&i%&G $e#$ami%&F

5 &i(i%& a%d $e ei(i%& #eedba 4 6 sha$ed de isio% ma4i%& 7 deb$ie#i%& a%d )$o ess e(a!uatio% 8 &$ou) #a i!itatio% 9
o%#!i t d"%ami s

10 mediatio%

21 22

Ge$a$di, Conflict "ngagement Training for (ealth Professionals- =Ge$a$di, Conflict "ngagement Training for (ealth Professionals, <-

01

1 2

o%#!i t assessme%t o%#!i t oa hi%&

3 a&$eeme%t ma%a&eme%t

Additio%a! )$i% i)!es a%d i%si&hts #$om the o%#!i t $eso!utio% #ie!d me$&e 'ith the s)e i#i hea!th a$e o%te8t to sha)e )$o&$ams a%d $es)o%ses to hea!th a$e o%#!i ts-

Uni-ue eatures of Healt&care

Robso% a%d Mo$$iso% hi&h!i&ht th$ee disti%&uishi%& #eatu$es o# hea!th a$e s"stems im)o$ta%t i% u%de$sta%di%& hea!th a$e o%#!i t a%d its ma%a&eme%t-2; Fi$st, hea!th a$e is a om)!e8 ada)ti(e s"stem ha$a te$i5ed b" o%sta%t ha%&e, #!uid !i%4a&es, #!e8ib!e $u!es de)e%de%t o% s)e i#i a to$s a%d s"stem histo$", !a$&e amou%ts o# data, mu!ti)!e #eedba 4 !oo)s, a%d !imited a ess to othe$s9 i%#o$matio%- This t")e o# s"stem &e%e$ates mo$e e$$o$s, thou&h it a!so has the )ote%tia! to be mo$e $es)o%si(e tha% othe$ s"stems- I%te$$e!ated om)o%e%ts o# om)!e8 s"stems a$e di##i u!t to di##e$e%tiate, ma4i%& it a ha!!e%&e to #u!!" ide%ti#" !i%4a&es a%d sou$ es o# o%#!i ts 'ithi% the s"stem-

Se o%d, s"stemati i%e*ua!ities a%d imba!a% es o# )o'e$, 4%o'!ed&e, a%d o%t$o! $eate st$o%&!" hie$a$ hi a! hea!th a$e e%(i$o%me%ts- These imba!a% es a##e t the $e!atio%shi)s bet'ee% )atie%ts a%d )$o(ide$s7 &$ou)s o# )$o(ide$s E%u$ses, do to$s, so ia! 'o$4e$s, a%d othe$sF7 t")es o# )$o(ide$s E)$ima$" a$e (s- s)e ia!ist a$e7 u$ati(e (e$sus )$e(e%tati(eF7 ma%a&eme%t a%d )$o(ide$s7 )a"e$s a%d ma%a&eme%t7 a%d )a"e$s a%d )atie%ts, amo%& othe$ $e!atio%shi)s-

2;

Rob Robso% a%d Gi%%" Mo$$iso%, BThe Fi%a! ADR F$o%tie$: Co%#!i t Reso!utio% i% Hea!th a$e,C CResolution ES)$i%& 233;F, 23620-

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Thi$d, due to di##e$e% es i% t$ai%i%& a%d )$o#essio%a! so ia!i5atio%, a to$s i% the s"stem o#te% ho!d 'ide!" di(e$&e%t u!tu$es a%d (a!ue s"stems- This sha)es ho' the" de#i%e a%d $es)o%d to o%#!i t- 2= The $a%&e o# a to$s a%d the e8te%t o# thei$ u!tu$a! a%d (a!ue di(e$&e% e $eate a u%i*ue e%(i$o%me%t #o$ hea!th a$e o%#!i t ma%a&eme%t- Ph"si ia%s, %u$ses, so ia! 'o$4e$s, )ha$ma ists, $is4 ma%a&e$s, hos)ita! admi%ist$ato$s, !a'"e$s a%d )atie%ts ma" a!! be sta4eho!de$s i% a si%&!e dis)ute- These st$ati#i atio%s a% #oste$ ide%tities st$o%&!" !i%4ed to om)ete%t )$a ti e o# o%e9s )$o#essio% a%d a to$s 'ith a ute a'a$e%ess o# om)eti%& )$io$ities bet'ee% the )a$ties- These #a to$s a% ma4e o%#!i ts )a$ti u!a$!" om)!e8 'ith mu!ti)!e sou$ es o# $esista% e to o%#!i t ma%a&eme%t, es)e ia!!" to'a$ds thi$d6)a$ties #$om outside the hea!th a$e $ea!m-

Culture and Conflict in Healt&care

Di##e$e%t u!tu$es a%d u!tu$a! ide%tities 'ithi% hea!th a$e a% ha(e si&%i#i a%t im)a t o% hea!th a$e o%#!i t ma%a&eme%t- Do to$s, %u$ses, admi%ist$ato$s, a%d hea!th a$e !a'"e$s, to %ame Dust a #e', o%stitute disti% t hea!th a$e sub u!tu$es-21 Di##e$e% es i% t$ai%i%&, (a!ues, )hi!oso)hies, ommu%i atio% st"!es, )$o#essio%a! e8)e tatio%s, a%d $o!es sha)e a))$oa hes to o%#!i t a%d st$u tu$e $es)o%ses to it- A%de$so% a%d D9A%to%io ite di##e$e% es i% the 'a"s that ADR )$o#essio%a!s Ema%" o# 'hom a$e atto$%e"sF a%d hea!th a$e )$o(ide$s ma4e se%se o# i%#o$matio% a%d the o%te8t a$ou%d them2<

The" %ote di##e$e% es i% !e&a! a%d medi a! edu atio% to'a$ds i%du ti(e (e$sus dedu ti(e

$easo%i%& a))$oa hes, hi&h!i&hti%& the im)a t that a% ha(e o% o%#!i t ma%a&eme%t edu atio% a%d i%te$(e%tio%s- La!ue a%d ide%tit" o%#!i ts amo%&st these )$o#essio%a! u!tu$es a% )ose si&%i#i a%t ha!!e%&es #o$ hea!th a$e o%#!i t ma%a&eme%t-

24 Fo$ #u$the$ omme%ta$" o% the $o!e o# u!tu$e i% hea!th a$e o%#!i t, see Deb$a Ge$a$di, BThe Cu!tu$e o# Hea!th a$e: Ho' P$o#essio%a! a%d O$&a%i5atio%a! Cu!tu$es Im)a t Co%#!i t Ma%a&eme%t,C Georgia State University Law Review 20, %o- = ESumme$ 2331F, A1@6A?37 a!so Daue$, BPosts $i)t o% Hea!th Ca$e Dis)ute Reso!utio%-C 25 Ge$a$di, BThe Cu!tu$e o# Hea!th a$eC7 Co!b" A%de$so% a%d Li%da D9A%to%io, BA Pa$ti i)ato$" A))$oa h to U%de$sta%di%& Co%#!i t i% Hea!th a$e,C Georgia State University Law Review 20 E2331F: A0@6A;326
A%de$so% a%d D9A%to%io, BA Pa$ti i)ato$" A))$oa h-C

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"elations&ips in Healt&care

Re!atio%shi)s a$e e%t$a! to ma%" hea!th a$e u!tu$es- Ethi a! a%d )$o#essio%a! %o$ms )!a e a hi&h )$emium o% the t$ust, $es)e t, a%d $es)o%sibi!it" i%(ested i% hea!th a$e )$o(ide$s9 $e!atio%shi)s 'ith both )atie%ts a%d 'ith othe$ hea!th a$e )$o(ide$s- I%te$(ie'ees su&&ested that hea!th a$e )$o(ide$ ide%tities a$e t")i a!!" !ose!" tied to the 'o$4 that the" do, )ossib!" mu h mo$e so tha% othe$ )$o#essio%s-

+" e%da%&e$i%& $e!atio%shi)s, hea!th a$e o%#!i ts th$eate% these )$o#essio%a! ide%tities a%d $e)utatio%s, 4e" as)e ts o# 'ho hea!th a$e )$o(ide$s see themse!(es to be- Com)ete%t )$a ti e o# o%e9s )$o#essio% has bee% ited as )a$ti u!a$!" e%t$a! to the ide%tit" o# ma%" hea!th a$e )$o(ide$s-2@ This )$o#essio%a! ide%tit" is hea(i!" dete$mi%ed b" a%d $e!ia%t o% $e!atio%shi)s- Ho%o$i%& a%d mai%tai%i%& the t$ust o# the )atie%t i% the hea!th a$e )$o(ide$ a%d #u!#i!!i%& the )$o(ide$9s $es)o%sibi!it" #o$ the hea!th a%d 'e!#a$e o# the )atie%t $e*ui$es %ot o%!" i%ta t $e!atio%shi)s 'ith the )atie%t but a!so #u% tio%i%& $e!atio%shi)s 'ith othe$ hea!th a$e )$o(ide$s- Fu$the$ b$oade%i%& the $e!atio%shi) %et'o$4 to i% o$)o$ate o% e$%s 'ith )$o#essio%a! $e)utatio% a%d !e&a ", mai%tai%i%& a%d $e)ai$i%& $e!atio%shi)s i% the #a e o# o%#!i ts that th$eate% those $e!atio%shi)s is at the o$e o# ma%" hea!th a$e o%#!i ts-

This shi#t to'a$ds $e!atio%shi) ma" su&&est i% $eased uti!i5atio% o# t$a%s#o$mati(e mediatio% a))$oa hesThese a))$oa hes )!a e i% $eased em)hasis o% em)o'e$me%t a%d $e o&%itio%, i%de)e%de%t o# a%" )a$ti u!a$ out ome to a mediatio%-2A Des)ite $e o&%itio% o# the im)o$ta% e o# $e!atio%shi)s, $iti*ues that t$a%s#o$mati(e mediatio% is )ate$%a!isti a%d im)$a ti a! a$e u%!i4e!" to be dimi%ished- 2? Gi(e% the st$i t

27

Rob Robso% a%d Gi%%" Mo$$iso%, BThe Fi%a! ADR F$o%tie$: Co%#!i t Reso!utio% i% Hea!th a$e,C CResolution ES)$i%& 233;F: 23rt and Science of

28 Che$"! Pi a$d, Pete$ +isho), Re%a Ram4a", a%d Nei! Sa$&e%t, The Mediation ETo$o%to: Emo%d Mo%t&ome$" Pub!i atio%s, Ltd: 233=F, 0030A

29 M"$a .a$$e% Ise%ha$t a%d Mi hae! S)a%&!e, Collaborative pproaches to Resolving Conflict EThousa%d Oa4s, CA: Sa&e Pub!i atio%s, 2333F, <;-

time o%st$ai%ts o% hea!th a$e )$o(ide$s, o%#!i t ma%a&eme%t i%te$(e%tio%sT'hethe$ mediatio% o$ othe$'ise T'i!! !i4e!" %eed to $etai% thei$ )$a&mati , )$ob!em6so!(i%& a)a it"- The )ote%tia! #o$ e8)a%di%& i%te$est6based )$ob!em so!(i%& a))$oa hes to i% o$)o$ate a &$eate$ #o us o% $e!atio%shi)s a%d i%si&hts #$om t$a%s#o$mati(e mediatio% is a% im)o$ta%t to)i #o$ #u$the$ i%(esti&atio%-

C&allenges in Healt&care Conflict Management St$u tu$ed hea!th a$e o%#!i t ma%a&eme%t $emai%s a $e!ati(e!" %e' #ie!d- As su h, it #a es ha!!e%&es a%d ba$$ie$s to its s)$ead- Some o# these 4e" ha!!e%&es i% !ude:

1. La 4 o# s"stemati5ed a'a$e%ess o# o%#!i t ma%a&eme%t o)tio%s- .he% a &ood o%#!i t

$eso!utio% )$o&$am e8ists at a #a i!it", must ma4e othe$s mo$e a'a$e o# it so that the" a$e%9t a#$aid to use it- O#te%times the o%#!i t e%&a&eme%t thi%4i%& G st$u tu$es G a ti(ities a$e %ot s"stemati5ed i% a #a i!it" eithe$- O$&a%i5i%&, !a$i#"i%&, a%d )ub!i i5i%& this i%#o$matio% is a% im)o$ta%t ste) i% $eati%& #u% tio%i%& s"stems-

2.

La 4 o# su))o$t #$om su)e$io$s #o$ o%#!i t ma%a&eme%t s"stems G i%te$(e%tio%s- .ithi% the hie$a$ hi a! o$&a%i5atio% o# hea!th a$e de!i(e$" teams, !a 4 o# su))o$t #$om su)e$io$s a%d de isio% ma4e$s at the to) a% de$ai! e##o$ts #o$ those be!o' to )$odu ti(e!" $es)o%d to o%#!i t- Fo$ e8am)!e, i% the o%te8t o# sha$ed de isio% ma4i%& i%te$(e%tio%s, %u$ses ma" #ea$ that do to$s mi&ht be u)set i# the" he!) 'ith the de isio%s o# the )atie%ts- As i% ma%" e%(i$o%me%ts it is %ot the %o$ma! $o!e #o$ %u$ses to *uestio% )h"si ia%s, this i%te$(e%tio% ma" be see% as th$eate%i%&- The same a))!ies #o$ medi a! $eside%ts a%d Du%io$ sta##Tthe" 'o%9t be ab!e to use thei$ %e'#ou%d s4i!!s E)e$ha)s a *ui$ed i% a t$ai%i%&F i# thei$ su)e$io$s do%9t su))o$t it- Good mode!i%& a%d su))o$t #$om abo(e is %e essa$" #o$ i%stitutio%a!i5i%& e##e ti(e o%#!i t e%&a&eme%t-

3.

La 4 o# time a%d mo%e" #o$ o%#!i t $eso!utio% a ti(ities- F$om t$ai%i%& to o%#!i t i%te$(e%tio%s to oa hi%& to usi%& s4i!!s i% a% i%te$a tio%, !a 4 o# time a%d mo%e" Ei% !udi%& !a 4 o# #i%a% ia! $eimbu$seme%t b" em)!o"e$s a%d b" i%su$a% e )$o(ide$s #o$ time s)e%t o% these a ti(itiesF a$e si&%i#i a%t hu$d!es- It is ha!!e%&i%& to be ab!e to )a" sta## i% a sta##6 a%d ash6st$a))ed hea!th a$e

0?

e%(i$o%me%t to &o to o%#!i t ma%a&eme%t t$ai%i%&s a%d to #i%d 'a"s to o(e$ thei$ shi#ts so that the" ha(e that time o##- .ith thousa%ds o# !i%i a! sta## 'o$4i%& i% ma%" hos)ita!s, it is tou&h to &et e(e$"o%e th$ou&h e(e% basi t$ai%i%&s- The %eed #o$ $e&u!a$ me%to$shi) a%d $e#$eshe$ t$ai%i%&s is a% added di##i u!t"-

4. I%#o$matio% &a)s about 'hat othe$s i% the hea!th a$e o%#!i t #ie!d a$e doi%&- Hea!th a$e
o%#!i t $eso!utio% e8)e$ts %eed to )ub!ish mo$e to he!) o(e$ ome these &a)s-

5.

La 4 o# $e o&%itio% b" ma%" hea!th a$e )$o(ide$s that the$e a$e o%#!i ts i% hea!th a$e, that )eo)!e ma" %eed he!) dea!i%& 'ith these )$ob!ems, a%d that see4i%& this he!) is o4a"-

6. Di##i u!ties ide%ti#"i%& a%d em)o'e$i%& ha%&e a&e%ts7. Hie$a$ hi a! ba$$ie$s i% hea!th a$e e%(i$o%me%ts- These hie$a$ hies a$e both
ho$i5o%ta!!" a $oss )$o#essio%s a%d (e$ti a!!" 'ithi% )$o#essio%s- I% a ademi tea hi%& e%te$s, the hie$a$ hies bet'ee% t$ai%ees a%d su)e$(iso$s a% !ea(e t$ai%ees #ee!i%& (u!%e$ab!e a%d $e!u ta%t to i%itiati(e di##i u!t o%(e$satio%s o$ a))!" o%#!i t $eso!utio% s4i!!s that the" do %ot see mode!ed b" su)e$io$s-;3

Conflict Management Training in Healt&care

The$e is a &$o'i%& !ite$atu$e o% o%#!i t ma%a&eme%t t$ai%i%& #o$ hea!th a$e- The Ame$i a% Hea!th
La'"e$s Asso iatio%9s Conflict Management Tool!it out!i%es a sta%da$d a))$oa h to o%#!i t ma%a&eme%t

t$ai%i%& #o$ hea!th a$e )$o#essio%a!s- The t$ai%i%&s a$e desi&%ed as #o$ma! modu!es to be de!i(e$ed b" om)ete%t o%#!i t ma%a&eme%t )$o#essio%a!s, eithe$ i%te$%a! sta## o$ outside o%su!ta%ts- Su&&ested
t$ai%i%& obDe ti(es a$e to edu ate )a$ti i)a%ts i% E0F u%de$sta%di%& the #ou%datio%a! )$i% i)!es o# o%#!i t

;3

E!!e% P'eibe!, Rose Go!dstei%, /oh% Ma%'a$i%&, a%d Me$idith Ma$4s, B.hat Sti 4s: Ho' Medi a! Reside%ts a%d A ademi Hea!th Ca$e Fa u!t" T$a%s#e$ Co%#!i t Reso!utio% T$ai%i%& #$om the .o$4sho) to the .o$4)!a e,C Conflict Resolution /uarterly 21, %o- ; ES)$i%& 233AF: ;=2-

23

ma%a&eme%t,;0 E2F ea$!" $e o&%itio% a%d i%te$(e%tio% i% $es)o%se to o%#!i t, E;F mai%tai%i%& obDe ti(it" 'hi!e !imiti%& subDe ti(it" a%d emotio%, E=F %eut$a! i%#o$matio% a%d #a t &athe$i%&, a%d E1F ommitme%t to #o!!o' the o%#!i t ma%a&eme%t )$o ess, )o!i ies, a%d )$o edu$es- ;2

Resea$ h #$om A%de$so% a%d D9A%to%io )oi%ts to the im)o$ta% e o# ADR )$o#essio%a!s 'o$4i%& mo$e !ose!" 'ith hea!th a$e )$o(ide$s o% the desi&% a%d im)!eme%tatio% o# o%#!i t ma%a&eme%t t$ai%i%& )$o&$ams- The" o%du ted a stud" o# hea!th a$e ADR )$o#essio%a!s E!a$&e!" atto$%e"sF a%d hea!th a$e )$o(ide$s 'ho dea! dai!" 'ith o%#!i t i%(o!(i%& )h"si ia%s- The stud" s)e i#i a!!" #o used o% the t'o &$ou)s9 )e$s)e ti(es o% the t")es a%d amou%ts o# o%#!i ts #a ed b" a%d i%(o!(i%& )h"si ia%s;;

Re&a$di%& time s)e%t o% o%#!i t,

hea!th a$e )$o(ide$s )e$ ei(ed that 13K o# )h"si ia% time 'as s)e%t i% o%#!i t o$ immi%e%t )ote%tia! o%#!i t situatio%s, a $ate t'i e that ADR e8)e$ts e8)e ted- The$e 'e$e dis $e)a% ies bet'ee% )e$ e)tio%s o# 'hi h $e!atio%shi)s 'e$e the &$eatest sou$ e o# o%#!i t #o$ )h"si ia%s- Se!e ti%& #$om a !ist o# si8 $e!atio%shi)s, ADR )$o#essio%a!s )e$ ei(ed the &$eatest sou$ e o# o%#!i t as do to$6i%su$a% e E;AKF, do to$6)atie%t E;0KF, a%d do to$6sta## E0;KF-;= This 'as i% si&%i#i a%t o%t$ast to the $esu!ts #$om hea!th a$e )$o(ide$s, 'ho sa' the &$eatest sou$ e o# o%#!i t as do to$6do to$ E21KF, do to$6admi%ist$atio% E22KF, a%d do to$6 i%su$a% e E0AKF- The i%di atio% that the do to$6)atie%t $e!atio%shi) is !ess )$ob!emati tha% ADR )$o#essio%a!s )e$ ei(ed a%d the do to$6do to$ $e!atio%shi) mo$e )$ob!emati has im)o$ta%t im)!i atio%s o% the desi&% a%d #o us o# o%#!i t $eso!utio% t$ai%i%&s-

31 The too!4it !ists the #ou%datio%a! )$i% i)!es %e essa$" to su))o$t o%#!i t ma%a&eme%t as: 0F a 'i!!i%&%ess to a 4%o'!ed&e the e8iste% e o# o%#!i t7 2F o)e% ommu%i atio%7 ;F dea!i%& 'ith o%#!i t 'ithi% a% e%(i$o%me%t o# mutua! $es)e t7 =F a e)ta% e a%d to!e$a% e o# di##e$e%t )e$s)e ti(es th$ou&h the )$o ess7 1F ommitme%t to #u%dame%ta! #ai$%ess7 <F edu ati%& a!! sta4eho!de$s about o%#!i t ma%a&eme%t7 @F de(e!o)i%& a o%#!i t ma%a&eme%t )$o ess 'ith )o!i ies a%d )$o edu$es 'ith i%)ut #$om sta4eho!de$s7 a%d AF ho!di%& sta4eho!de$s a ou%tab!e to use the o%#!i t ma%a&eme%t )$o ess- See Ame$i a% Hea!th La'"e$s Asso iatio%, Conflict Management Tool!it E233?F, htt):GG'''-hea!th!a'"e$s-o$&GResou$ esGADRGPa&esGADRToo!4it-as)8 Ea essed 2? Ma" 2303F, =Ame$i a% Hea!th La'"e$s Asso iatio%, Conflict Management Tool!it, 1A%de$so% a%d D9A%to%io, BEm)i$i a! I%si&hts,C 0160AThe si8 $e!atio%shi)s 'e$e do to$6)atie%t7 do to$6#ami!"7 do to$6sta##7 do to$6do to$7 do to$6 admi%ist$atio%7 do to$6i%su$a% e-

32 33 34

20

Additio%a!!", the" #ou%d that both ADR )$o#essio%a!s a%d hea!th a$e )$o(ide$s be!ie(e that the o%#!i t ma%a&eme%t s4i!!s $e*ui$ed b" )h"si ia%s a$e t$ai%ab!e-;1 +oth su&&ested that t$ai%i%& )h"si ia%s to dea! 'ith $e!atio%a! as)e ts o# o%#!i t ou!d e!imi%ate 13K o# o%#!i t i% hea!th a$e- The" %oted that )e$ e)tio%s o# o%#!i t e%&a&eme%t st"!es (a$ied a%d t$ai%i%& %eeds (a$ied, both 'ithi% a%d a $oss &$ou)s, hi&h!i&hti%& the im)o$ta% e o# )$o)e$ %eeds assessme%ts )$io$ to a%" t$ai%i%&-

Last!", the$e 'as di(e$&e% e o% 'he% t$ai%i%& shou!d ha))e%- Ma%" ADR )$o#essio%a!s su&&ested o%ti%ui%& edu atio% a%d )$o#essio%a! de(e!o)me%t (e%ues as su##i ie%t t$ai%i%& #o$ums, 'hi!e hea!th a$e )$o(ide$s !aimed that o%#!i t ma%a&eme%t s4i!!s %eeded to be tau&ht ea$!ie$, as )a$t o# a )h"si ia%9s i%itia! t$ai%i%&- Reside% " 'as see% as the most $iti a! )hase, as this 'as ited as the )e$iod du$i%& 'hi h )h"si ia%s9 o%#!i t $es)o%ses a$e sha)ed- The$e 'e$e o% e$%s that e(e% &ood o%#!i t $eso!utio% s4i!!s tau&ht du$i%& medi a! s hoo! 'ou!d be Bu%tau&htC i% $eside% " i# mode!i%& #$om su$$ou%di%& )h"si ia%s 'as )oo$- The im)a t o# mode!i%& a%d me%to$i%& #$om mo$e se%io$ $eside%ts a%d atte%di%& )h"si ia%s du$i%& the $eside% " "ea$s 'as see% as a )$ima$" #a to$ sha)i%& )h"si ia%s9 #utu$e a))$oa hes to o%#!i t- This su&&ested ta))i%& i%to the u%i*ue a))$e%ti eshi) mode! o# hea!th a$e edu atio% a%d $e#o usi%& o%#!i t $eso!utio% t$ai%i%& o% me%to$i%&, %ot !e tu$i%&- .hi!e o%#!i t $eso!utio% ou$ses #o$ $eside%ts 'e$e sti!! ad(ised, i% $easi%& ado)tio% o# a t$ai%6the6t$ai%e$s a))$oa h 'as $e omme%ded-

Re e%t $esea$ h #$om P'eibe! et a!- demo%st$ated that e(e% sho$t )$o#essio%a! de(e!o)me%t t$ai%i%&s o% o%#!i t $eso!utio% a% )ositi(e!" im)a t the o%#!i t ma%a&eme%t s4i!!s o# hea!th a$e )$o#essio%a!s- ;< A% idea that eme$&ed out o# !o%&itudi%a! $esea$ h 'ith medi a! $eside%ts 'as the be%e#it o# setti%& aside time #o$ 'ee4!" o$ mo%th!" dis ussio%s o# &e%e$a! BissuesC a$isi%& i% a medi a! u%it- The e8iste% e o# a disti% t (e%ue 'he$e $eside%ts 'e$e e% ou$a&ed to dis uss di##i u!t issues 'as see% as he!)i%& to $emo(e some o# the i%hibitio%s $eated b" the hie$a$ h" bet'ee% $eside%ts a%d atte%di%& )h"si ia%s, a hie$a$ h" 'hi h

35 36

A%de$so% a%d D9A%to%io, BEm)i$i a! I%si&hts,C 01, 0<P'eibe!, et a!-, B.hat Sti 4s-C

22

ou!d othe$'ise dissuade $eside%ts #$om a 4%o'!ed&i%& ha!!e%&es the" a$e #a i%&- ;@ C!i%i ia%s a%d #a u!t" a!so $e)o$t 'a%ti%& $e&u!a$, i%#o$ma! sessio%s to dis uss thei$ e8)e$ie% es a))!"i%& o%#!i t $eso!utio% s4i!!s-;A C$eati%& these o))o$tu%ities 'e$e see% as %e essa$" to $ei%#o$ e the !ea$%i%& that o u$s i% o%#!i t ma%a&eme%t t$ai%i%&s-

Dis$u)ti(e beha(io$ )$ese%ts a% additio%a! a$e%a #o$ o%#!i t ma%a&eme%t t$ai%i%&- /oh%so% su&&ests edu atio% o% team'o$4, o!!abo$atio%, a%d )$odu ti(e )$ob!em so!(i%& as o%e im)o$ta%t om)o%e%t o# so!utio%s to o%ti%ui%& )$ob!ems 'ith dis$u)ti(e beha(io$ b" both )h"si ia%s a%d %u$ses-;?

Re omme%datio%s i% !ude sta$ti%& this edu atio% ea$!", s)e i#i a!!" i% medi a! a%d %u$si%& s hoo!s, a%d $eati%& o))o$tu%ities #o$ i% $eased u%de$sta%di%& o# othe$s9 %eeds, su h as a$$a%&i%& #o$ medi a! stude%ts to shado' %u$ses-

Ge$a$di has '$itte% e8te%si(e!" o% hea!th a$e o%#!i t ma%a&eme%t t$ai%i%&, i% !udi%& a 2303 'hite )a)e$ o% o%#!i t e%&a&eme%t t$ai%i%& #o$ hea!th )$o#essio%a!s- =3 Je" $e omme%datio%s #$om this !ite$atu$e i% !ude the #o!!o'i%&:

1.

Recogni&e that training alone can3t solve e#isting conflicts - Co%#!i t t$ai%i%& a% be )ai$ed 'ith a% ADR i%te$(e%tio% to ha%d!e a% e8isti%& )$ob!em, but t$ai%i%& does %ot su##i e #o$ a% ADR i%te$(e%tio%- O$&a%i5atio%s #a i%& o%#!i t shou!d %ot assume t$ai%i%& 'i!! #i8 the )$ob!em-

2.

"#pand *pportunities for Training- Fo$ time a%d ost e##i ie% ", a%d as 'e!! as to )$o(ide o))o$tu%ities #o$ a))!i atio% o# %e'!"6!ea$%ed s4i!!s, o%#!i t e%&a&eme%t t$ai%i%&s shou!d be

P'eibe!, et a!-, B.hat Sti 4s,C ;=;/oh%so%, B+ad +!ood,C 03Ge$a$di, Conflict "ngagement Training for (ealth Professionals7 see a!so, Ge$a$di, BUsi%& Im)$o(isatio% to De(e!o) Co%#!i t Reso!utio% S4i!!s,C o%!i%e at Mediate- om, O t- 2330, htt):GG'''-mediate- omGGa$ti !esG&e$adi0- #m Ea essed 2? Ma" 2303F7 a%d Ge$a$di, BCo%#!i t Ma%a&eme%t T$ai%i%& #o$ Hea!th Ca$e P$o#essio%a!s,C CResolution ES)$i%& 233;F-

37 38 39 40

P'eibe!, et a!-, B.hat Sti 4s,C ;=2-

2;

a!i&%ed 'ith o%tem)o$a$" o$&a%i5atio%a! &oa!s a%d issues- Co%#!i t t$ai%i%& a% be i%te&$ated 'ith bioethi s )$o&$ams, &$a%d $ou%ds, MUM $ou%ds, )atie%t sa#et" i%itiati(es, !eade$shi) de(e!o)me%t, teambui!di%& a%d team t$ai%i%& e8e$ ises, o$&a%i5atio%a! ha%&e i%itiati(es, a%d /oi%t Commissio% a $editatio% e##o$ts-

3.

Select the correct trainers+ T$ai%e$ !e&itima " is im)o$ta%t i% the #a e o# hea!th a$e )$o(ide$s s4e)ti a! o# o%#!i t ma%a&eme%t- Gi(e% hea!th a$e )$o(ide$ u!tu$es that o#te% ide%ti#" themse!(es as disti% t #$om %o%6 !i%i ia%s, t$ai%e$s %eed a% a))$e iatio% o# !i%i a! u!tu$e a%d a 'o$4i%& u%de$sta%di%& o# the hea!th a$e e%(i$o%me%t + The" must u%de$sta%d the di##e$e%t d"%ami s i% hea!th a$e a%d tai!o$ t$ai%i%& #o$ the s)e i#i audie% e a%d the o%#!i ts the" #a ePa$t%e$ed t$ai%i%&s a$e &oodTo%e !i%i ia% 'ith some ADR s4i!!s a!o%&side a% ADR )$o#essio%a!- The 4e" is the abi!it" to s)ea4 'ith autho$it" a%d u%de$sta%di%& o# thei$ issues a%d to a%s'e$ *uestio%s )a$ti i)a%ts b$i%& u) i% the t$ai%i%&-

4. Support Conflict Competency through Communities of Practice+ Fo$ beha(io$ ha%&e,

t$ai%i%& %eeds to be $ei%#o$ ed th$ou&h $e&u!a$ #o!!o'6u) a ti(ities- Su))o$ti%& i%te%tio%a! ommu%ities o# )$a ti e 'he$ei% hea!th a$e )$o#essio%a!s a% meet to dis uss o%#!i ts the" a$e #a i%&, sha$e ideas, a%d #u$the$ e8)!o$e o%#!i t e%&a&eme%t a% be a% e##e ti(e 'a" to e8)a%d o%#!i t om)ete% " 'ithi% hea!th a$e e%(i$o%me%ts-

5.

4e fast+ The t$eme%dous time a%d #i%a% ia! )$essu$es o% hea!th a$e )$o(ide$s a%d hea!th a$e s"stems o%st$ai% 'hat is )ossib!e 'ith t$ai%i%&s- T$ai%i%&s must be o% ise, #o used, a%d use e8)e$ie%tia!, ha%ds6o% methodo!o&ies- E8)e tatio%s a$e hi&h a%d t$ai%e$s %eed to be )$e)a$ed to %a(i&ate the ha!!e%&es asso iated 'ith hea!th a$e ide%tities a%d u!tu$es-

2 =

LITE"ATU"E "E.IE%

The #o!!o'i%& !ite$atu$e $e(ie' su$(e"s the )$ima$" #ou$ d"%ami s i% hea!th a$e o%#!i ts: )$o(ide$6)$o(ide$ o%#!i t7 )$o(ide$6)atie%t o%#!i t7 )atie%t6)a"e$ o%#!i t7 a%d )$o(ide$6admi%ist$atio% o%#!i t-

I/ 0ro1ider 2 0ro1ider Conflict

The !a$&est )oo! o# o%#!i ts 'ith )ote%tia!!" the most se$ious a%d 'ides)$ead im)a t is )$o(ide$ > )$o(ide$ o%#!i ts- These o%#!i ts o u$ amo%& a%d bet'ee% a!! t")es o# !i%i a! a$e&i(e$s, o#te% 'ith hi&h i% ide% e $ates- Dis$u)ti(e beha(io$ is o%e as)e t o# )$o(ide$ o%#!i t, 'hi!e dema%d #o$ i% $eased o!!abo$atio% amo%&st )$o(ide$s is a%othe$-

%isruptive 4ehavior

The Ame$i a% Co!!e&e o# Ph"si ia% E8e uti(es9 233? Do to$ > Nu$se +eha(io$ Su$(e" #ou%d that ?AK o# those su$(e"ed had 'it%essed a% i% ide%t o# dis$u)ti(e beha(io$ bet'ee% %u$ses a%d )h"si ia%s i% the !ast "ea$- =0 ;3K o# )a$ti i)a%ts $e)o$ted 'it%essi%& bad beha(io$ mu!ti)!e times )e$ "ea$7 21K mo%th!"7 ;3K 'ee4!"7 a%d 03K dai!"- Ph"si ia%s 'e$e most #$e*ue%t!" ited as $es)o%sib!e #o$ the dis$u)ti(e beha(io$, thou&h bad beha(io$ 'as a!so %oted i% %u$ses-=2 Res)o%de%ts ited )oo$ ommu%i atio% a%d a #u%dame%ta! !a 4 o# $es)e t bet'ee% )h"si ia%s a%d %u$ses as the )$ima$" auses o# o%#!i t-=;

41 The su$(e" 'as emai!ed to a))$o8imate!" 0;,333 do to$s a%d %u$ses7 2033 $etu$%ed the om)!eted su$(e"- <@K o# the )a$ti i)a%ts 'e$e %u$ses, ;;K )h"si ia%s- The su$(e" i% !uded the #o!!o'i%& a ti(ities as dis$u)ti(e beha(io$: "e!!i%&7 u$si%&7 de&$adi%& omme%ts a%d i%su!ts7 $e#usi%& to 'o$4 to&ethe$7 $e#usi%& to s)ea4 to ea h othe$7 s)$eadi%& ma!i ious $umo$s7 i%a))$o)$iate Do4i%&7 t$"i%& to &et someo%e dis i)!i%ed u%Dust!"7 t$"i%& to &et someo%e #i$ed u%Dust!"7 th$o'i%& obDe ts7 se8ua! ha$assme%t7 )h"si a! assau!t7 othe$- See /oh%so%, B+ad +!ood,C <60042 .hi!e mu h o# the !ite$atu$e #o uses o% )h"si ia%s as the )e$)et$ato$s o# bad beha(io$, othe$ studies ha(e do ume%ted abusi(e beha(io$ o u$$i%& 'ith #$e*ue% " amo%& %u$ses, )ha$ma ists, i% $adio!o&" de)a$tme%ts, a%d i% the !abo$ato$"- See A-H- Rose%stei% a%d M- OVDa%ie!, BDis$u)ti(e beha(io$ a%d !i%i a! out omes: Pe$ e)tio%s o# %u$ses a%d )h"si ia%s,C merican $ournal of .ursing 031, %o- 0 E2331F: 1=6<=7
21

I% Se%ti%e! E(e%t A!e$t N=3 Eissued /u!" 3?, 233AF, the /oi%t Commissio% stated that o$&a%i5atio%s must add$ess i%timidati%& a%d dis$u)ti(e beha(io$ b" hea!th a$e )$o(ide$s i% the i%te$est o# *ua!it" o# a$e a%d a u!tu$e o# sa#et"==

The" ited $esea$ h sho'i%& o$$e!atio%s bet'ee% dis$u)ti(e beha(io$ a%d medi a! e$$o$s, )oo$ )atie%t
=1

satis#a tio%, )$e(e%tab!e ad(e$se out omes, i% $eased ost o# a$e, a%d sta## $ete%tio%-

The 2331 Si!e% e Ji!!s stud" do ume%ted that hea!th a$e )$o(ide$s a$e $e!u ta%t to e%&a&e i% di##i u!t o%(e$satio%s about ma%" ommo% o% e$%s a%d )$ob!ems i%(o!(i%& thei$ o'o$4e$s=<

.hi!e the

maDo$it" o# )$o(ide$s 'it%essed ma%" o# the t")es o# )$ob!ems su$(e"ed, !ess tha% 03K s)o4e u)23K o# )h"si ia%s $e)o$ted seei%& ha$m ome to )atie%ts as a $esu!t o# these o% e$%s a%d 2;K o# %u$ses said the" 'e$e o%side$i%& !ea(i%& thei$ )ositio% as a $esu!t o# these o% e$%s- I% o%t$ast, the 03K 'ho #e!t o%#ide%t e%ou&h i% thei$ abi!it" to ommu%i ate thei$ o% e$%s 'e$e $e)o$ted to obse$(e bette$ )atie%t out omes, 'o$4 ha$de$, be mo$e satis#ied, a%d be mo$e ommitted to sta"i%& i% thei$ Dobs- The stud" su&&ests that a(oida% e o# o%#!i t a%d #ai!u$e to ommu%i ate o% e$%s th$eate%s )atie%t sa#et", $edu es sta## satis#a tio%, a%d i% $eases sta## tu$%o(e$- =@

Thou&h these )$o(ide$ > )$o(ide$ o%#!i ts im)a t $e!atio%shi)s 'ith )atie%ts, )$o(ide$ o%#!i ts a$e #$e*ue%t!" dea!t 'ith th$ou&h ha%%e!s se)a$ate #$om )atie%t6)$o(ide$ o%#!i ts- Ma%" hos)ita! o%#!i t

a!so, I%stitute #o$ Sa#e Medi atio% P$a ti es, Survey on wor!place intimidation E233;F, htt):GG'''-ism)-o$&GSu$(e"Gsu$(e"$esu!tsGSu$(e"3;00-as) Ea essed 2A Ma" 2303FThe /oi%t Commissio%, BSe%ti%e! E(e%t A!e$t N=3: +eha(io$s that U%de$mi%e a Cu!tu$e o# Sa#et",C E/u!" 3?, 233AF, htt):GG'''-Doi%t ommissio%-o$&Gse%ti%e!e(e%tsGse%ti%e!e(e%ta!e$tGseaM=3-htm Ea essed 2A Ma" 2303FThe /oi%t Commissio%, BSe%ti%e! E(e%t A!e$t N=3-C This stud" s)o%so$ed b" Lita!Sma$ts a%d the Ame$i a% Asso iatio% o# C$iti a! Ca$e Nu$ses su$(e"ed se(e% to)i s o# o% e$% i%(o!(i%& hea!th a$e )$o(ide$s: b$o4e% $u!es7 mista4es7 !a 4 o# su))o$t7 i% om)ete% e7 )oo$ team'o$47 dis$es)e t7 a%d mi $oma%a&eme%t- See Da(id Ma8#ie!d, et a!-, BE8e uti(e Summa$",C Silence 5ills) The Seven Crucial Conversations for (ealthcare E2331Fhtt):GG'''-si!e% e4i!!s- omGUPDLGSi!e% eJi!!sE8e Summa$"-)d# Ea essed 2A Ma" 2303F-

43 44 45 46

/oh%so%, B+ad +!ood,C <-

47 /ose)h G$e%%", BC$u ia! Co%(e$satio%s: The Most Pote%t Fo$ e #o$ E!imi%ati%& Dis$u)ti(e +eha(io$,C Physician "#ecutive $ournal of Medical Management ENo(GDe 233?F: ;36;;htt):GG%et-a )e-o$&GMembe$sO%!"G)eDou$%a!G233?GNo(De GG$e%%"M/ose)h-)d# Ea essed 2A Ma" 2303F2<

ma%a&eme%t s"stems (ie' sta## o%#!i t as a% HR issue o$ a sta## 'e!!6bei%& o% e$%7 as a $esu!t, ma%" dis)ute $eso!utio% )$o&$ams ma" %ot dea! 'ith it- =A As )$o(ide$ o%#!i t is i% $easi%&!" bei%& a 4%o'!ed&ed as a maDo$ !iabi!it" a%d dis$u)tio% i% hea!th a$e, it is be omi%& a !a$&e$ #o us #o$ o%#!i t ma%a&eme%t s"stems a%d t$ai%i%&s-

E##o$ts to im)$o(e $e!atio%shi)s, ommu%i atio%, a%d $e o&%itio% a$e at the hea$t o# attem)ts to o(e$ ome dis$u)ti(e beha(io$- This )$ese%ts o))o$tu%ities #o$ t$a%s#o$mi%& $e!atio%shi)s b" $e#o usi%& o% ommo% &oa!s, a 4%o'!ed&i%& a ommo% desi$e to be $es)e ted a%d !iste%ed to i% the 'o$4)!a e, a%d e8)!o$i%& hea!thie$ $es)o%ses to o%#!i t- I% the o%te8t o# the Si!e% e Ji!!s Stud", e##o$ts ha(e bee% made to t$ai% )$o(ide$s to s)ea4 u) about the issues a%d o% e$%s the" )$e(ious!" i&%o$ed- The te h%i*ues %eeded #o$ these di##i u!t o%(e$satio%s d$a' hea(i!" #$om i%te$est6based %e&otiatio% a%d mediatio% a))$oa hes- Data #$om a $iti a!6 o%(e$satio% t$ai%i%& )$o&$am at Mai%e Ge%e$a! Hea!th hos)ita! sho'ed si&%i#i a%t EA360<3KF i% $eases i% )$o(ide$s9 'i!!i%&%ess to s)ea4 u) i% situatio%s that th$eate%ed )atie%t sa#et", i%(o!(ed dis$u)ti(e beha(io$, o$ e8hibited )oo$ team'o$4=?

Simi!a$!", the 233A /oi%t Commissio% se%ti%e! a!e$t ad(o ated i%te$6)$o#essio%a! dia!o&ues to )$oa ti(e!" add$ess o%#!i ts a%d im)$o(e ommu%i atio% a%d o!!abo$atio%, amo%& othe$ su&&estio%s-13 The /oi%t Commissio% 'e%t o% i% 233? to $e*ui$e as )a$t o# its a $editatio% sta%da$ds that hea!th a$e o$&a%i5atio%s

estab!ish )o!i ies a%d )$o edu$es #o$ o%#!i t ma%a&eme%t, i% !udi%& a )$o ess #o$ ma%a&i%& dis$u)ti(e a%d i%a))$o)$iate beha(io$-10 Thou&h the /oi%t Commissio% has "et to s"stemati a!!" e%#o$ e this $e*ui$eme%t, the e8iste% e o# the sta%da$d se$(es as a si&%i#i a%t #o$ e #o$ im)$o(i%& o%#!i t ma%a&eme%t i% hea!th a$e-

48 Ad(e$se e(e%t dis !osu$e )$o&$ams i% $easi%&!" aim to meet the %eeds o# the )$o(ide$ i%(o!(ed 'ith the ad(e$se e(e%t, i% $e o&%itio% that )$o(ide$ st$ess a$isi%& #$om these $ises a% ha(e $i))!e e##e ts o% othe$ as)e ts o# the 'o$4)!a eG$e%%", BC$u ia! Co%(e$satio%s,C ;36;;The /oi%t Commissio%, BSe%ti%e! E(e%t A!e$t N=3-C Sta%da$d LD-3;-30-30 a%d E!eme%ts o# Pe$#o$ma% e #o$ LD-3;-30-30- /oi%t Commissio% Resou$ es, The $oint Commission ccreditation Standards for (ospitals EOa4b$oo4 Te$$a e, IL: /oi%t Commissio% o% A $editatio% o# Hea!th a$e O$&a%i5atio%, 233?F-

49 50 51

2@

Communication and Collaboration

A)a$t #$om dis$u)ti(e beha(io$, )$o(ide$ o%#!i t a$ises i% the o%te8t o# mu!tidis i)!i%a$" a$e teamsT$aditio%a! mode!s o# auto%omous de isio% ma4i%& 'ith st$i t )$o#essio%a! hie$a$ hies bet'ee% )$o(ide$s !ash 'ith i% $easi%& e8)e tatio%s #o$ o!!abo$atio% o% mu!tidis i)!i%a$" teams, )atie%t a$e, hos)ita! ommittees, )ub!i hea!th issues, tea hi%&, a%d $esea$ h12

+a$$ie$s to su h o!!abo$atio%

a$ise #$om st$u tu$a! ha!!e%&es su h as )o'e$ imba!a% es E%e&otiati%& at a% u%e(e% tab!eF7 di##e$e%t )$o#essio%a! a%d edu atio%a! u!tu$es7 time )$essu$es7 te%de% ies to dise%&a&e #$om o%#!i t Esi!e% eF7 #ea$ o# $eta!iatio%7 a%d a !a 4 o# t$ai%i%& o% ho' to bui!d teams a%d #u% tio% o!!abo$ati(e!"- Su o!!abo$atio% amo%& )$o(ide$s 'i!! $e*ui$e edu ati%& )$o(ide$s o% di##e$e%t a))$oa hes to ommu%i atio%, #a i!itatio%, )$ob!em so!(i%&, de isio% ma4i%&, a%d o%#!i t e%&a&eme%tess#u!

The Pe%%s"!(a%ia Hos)ita! i% Phi!ade!)hia i%t$odu ed its U%it +ased C!i%i a! Leade$shi) P$o&$am EU+CLPF i% a% e##o$t to im)$o(e *ua!it" a%d )atie%t sa#et"1;

The )$o&$am #o used o% im)$o(i%&

$e!atio%shi)s bet'ee% %u$ses a%d )h"si ia%s i% hea!th a$e de!i(e$" b" $eati%& ha%%e!s #o$ i% $eased ommu%i atio%, o!!abo$atio%, a%d sha$ed o'%e$shi) a%d $es)o%sibi!it" #o$ )atie%t a$e- I% the th$ee "ea$s si% e it 'as i%stituted, the )$o&$am has sho'% im)$o(eme%ts i% *ua!it" a%d sa#et" o# a$e as 'e!! as im)$o(ed %u$se6)h"si ia% o!!abo$atio% a%d Dob satis#a tio%1=

The Pe%%s"!(a%ia Hos)ita! U+CLP is o%!" o%e o# ma%" e##o$ts u%de$'a" to t$a%s#o$m $e!atio%shi)s bet'ee% hea!th a$e )$o(ide$s th$ou&h $est$u tu$i%& hea!th a$e de!i(e$" s"stems- Hea!th a$e o%#!i ts a%d

Pe%%s"!(a%ia Hos)ita! is a tea hi%& i%stitutio% a##i!iated 'ith the U%i(e$sit" o# Pe%%s"!(a%ia Hea!th S"stem- See Mi hae! +u 4!e", /oh% Lau$se%, a%d Li to$ia Ota$o!a, BSt$e%&the%i%& Ph"si ia%6Nu$se Pa$t%e$shi)s to Im)$o(e Sua!it" a%d Patie%t Sa#et",C Physician "#ecutive $ournal of Medical Management ENo(GDe 233?F: 2=6 2A- htt):GG%et-a )e-o$&GMembe$sO%!"G)eDou$%a!G233?GNo(De G+u 4!e"MMi hae!-)d# Ea essed 2A Ma" 2303F-

52 53

P'eibe!, et a!-, B.hat Sti 4s,C ;20-

54

+u 4!e", Lau$se%, a%d Ota$o!a, BSt$e%&the%i%& Ph"si ia%6Nu$se Pa$t%e$shi)s-C

2A

e##i ie%t $es)o%ses to them a$e e%t$a! as)e ts o# these i%%o(ati(e a))$oa hes to hea!th a$e de!i(e$"- Co%#!i t $eso!utio% theo$" a%d )$o esses a$e imbedded 'ithi% ma%" o# the eme$&i%& s"stems- Hea!th a$e de!i(e$" s ie% e a%d its $e!atio%shi) to hea!th a$e o%#!i t is eme$&i%& as a 4e" a$ea o# o%#!i t ma%a&eme%t )$a ti e a%d $esea$ h-

II/ 0atient 2 0ro1ider Conflict

Patie%t > )$o(ide$ dis)utes o%stitute the o$e o# 'hat ma%" ha(e t$aditio%a!!" o%side$ed hea!th a$e ADR- Fami!" membe$s o# the )atie%ts a$e 4e" )a$ti i)a%ts i% these dis)utes, 'ith $is4 ma%a&eme%t, !e&a!, )atie%t sa#et", a%d *ua!it" o# a$e de)a$tme%ts othe$ ommo% sta4eho!de$s.hi!e a %e essa$i!" i% om)!ete e##o$t, I ha(e hose% to ate&o$i5e the !ite$atu$e o% this d"%ami i%to #ou$ &$ou)i%&s: Commu%i atio%, Patie%t Sa#et", a%d Sua!it" o# Ca$e7 Ad(e$se Out omes a%d Dis !osu$e7 Sha$ed De isio% Ma4i%&7 a%d Ethi s Co%#!i ts-

A- Commu%i atio%, Patie%t Sa#et" a%d Sua!it" o# Ca$e

Commu%i atio% )!a"s a e%t$a! $o!e i% a% e8te%si(e $a%&e o# o%#!i ts bet'ee% )$o(ide$s a%d )atie%tsCommo% e8am)!es i% !ude o% e$%s about )e$ ei(ed e$$o$s, oo$di%atio% bet'ee% !e(e!s o# a$e a%d )$o(ide$s, )atie%t om)$ehe%sio% o# )$o edu$es a%d t$eatme%t )!a%s, medi atio% om)!ia% e, o% e$%s o(e$ o%ti%uit" o# a$e Ea%d o%ti%uit" o# a$e )$o(ide$sF, )ai% ma%a&eme%t, !e%&th o# sta", !e(e! o# a$e, se$(i es a%d e*ui)me%t, ost o# t$eatme%t, i%#o$med o%se%t, )$i(a " a%d o%#ide%tia!it"-11 Re!atio%shi), (a!ue, st$u tu$a!, i%te$est, a%d data o%#!i ts a!! a$ise bet'ee% )$o(ide$s a%d )atie%ts-

11

Da!e Het5!e$, Li$&i%ia Mo$$iso%, Deb$a Ge$a$di, a%d Lo$$ai%e Sa% he5 Ha"es, BCu$i%& Co%#!i t: A )$es $i)tio% #o$ ADR i% hea!th a$e,C %ispute Resolution Maga&ine EFa!! 233=F: 16@-

2?

The most si&%i#i a%t i%sta% es o# ommu%i atio%6based o%#!i t i%(o!(e )atie%t sa#et" a%d *ua!it" o# a$eCo% e$% 'ith a(oidab!e medi a! e$$o$s has i% $eased the %eed #o$ &$eate$ o!!abo$atio% bet'ee% )$o(ide$s a%d )atie%ts, 'ith e##e ti(e ommu%i atio% at the hea$t o# this o!!abo$atio%- The #ai!u$e to sha$e i%#o$matio% T'hethe$ due to time o%st$ai%ts, a $e!u ta% e to Bbothe$C the )$o(ide$, o$ #ee!i%&s that it is %ot a))$o)$iate #o$ a )atie%t to o##e$ i%#o$matio% u%so!i itedT o%t$ibutes to medi a! e$$o$s, misdia&%oses, a%d u%%e essa$" t$eatme%t- Poo$ ommu%i atio% a% !ead to a !a 4 o# )atie%t t$ust i% hea!th a$e )$o(ide$s, 'ith det$ime%ta! im)a ts o% both )atie%t satis#a tio% a%d *ua!it" o# a$e )$o(ided-1< La%&ua&e a%d u!tu$a! ba$$ie$s a% a!so !ead to b$ea4do'%s i% ommu%i atio% a%d subse*ue%t !oss o# t$ust-

Dissatis#a tio% 'ith the ommu%i atio% s4i!!s o# hea!th a$e )$o(ide$s o$ the *ua!it" o# a$e $e ei(ed o#te% !eads to o##i ia!!" $e&iste$ed )atie%t om)!ai%ts- Ma%" o# these om)!ai%ts a$e ha%d!ed th$ou&h me ha%isms asso iated 'ith Sua!it" Assu$a% e, Patie%t Re!atio%s, o$ Ris4 Ma%a&eme%t de)a$tme%ts- The Jaise$ Pe$ma%e%te Hea!th Ca$e OmbudsGMediato$ )$o&$am is a% e8am)!e o# a )a$ti u!a$!" 'e!!6i%te&$ated a))$oa h that e8)a%ds the #o us o% ommu%i atio% to the i%stitutio%a! om)!ai%t6ha%d!i%& a%d )atie%t su))o$t !e(e!-

Mediatio% has bee% used to ha%d!e )h"si ia% mis o%du t om)!ai%ts that do %ot i%(o!(e ma!)$a ti e !aims- I% the 0??3s, the Massa husetts +oa$d o# Re&ist$atio% i% Medi i%e 'ith su))o$t #$om the P$o&$am #o$ Hea!th Ca$e Ne&otiatio% a%d Co%#!i t Reso!utio% at Ha$(a$d U%i(e$sit" )i!oted a mediatio% )$o&$am #o$ om)!ai%ts a&ai%st )h"si ia%s that a))ea$ed to a$ise #$om )oo$ ommu%i atio%, %ot ma!)$a ti e o% e$%s- Des)ite $ea hi%& a mutua!!"6satis#a to$" a&$eeme%t i% ?3K o# the ases mediated, the )$o&$am 'as dis o%ti%ued #o$ !a 4 o# #u%di%&The Ca%adia% Co!!e&e o# Ph"si ia%s a%d Su$&eo%s o)e$ated a simi!a$ mediatio% )$o&$am #o$ )h"si ia% mis o%du t om)!ai%ts- O(e$ the #i$st #i(e "ea$s E0??260??@F, the

1<

+u 4!e", Lau$se%, a%d Ota$o!a, BSt$e%&the%i%& Ph"si ia%6Nu$se Pa$t%e$shi)s,C 2<;3

)$o&$am a hie(ed a su

ess#u! sett!eme%t $ate o# A=K- Ho'e(e$, i% 0??? the )$o&$am 'as dis o%ti%ued

due to a d$o) i% sett!eme%t $ates a%d the amou%t o# time it too4 to o%(e%e mediatio%-1@

Mediatio% has a!so bee% used i% !o%&6te$m a$e #a i!ities to $eso!(e *ua!it"6o#6!i#e dis)utes bet'ee% sta##, $eside%ts, a%d thei$ #ami!ies1A

Some %u$si%& homes ha(e t$ai%ed sta## o% o%#!i t ma%a&eme%t

1?

te h%i*ues7 othe$s use mediatio% #o$ dis)utes bet'ee% $eside%ts o# the !o%&6te$m a$e #a i!it"-

Most t$ai%i%& o% ommu%i atio% that is o##e$ed as )a$t o# medi a! s hoo!, %u$si%& s hoo!, o$ $eside% ies #o uses o% ommu%i atio% s4i!!s to im)$o(e this )$o(ide$ > )atie%t d"%ami - .hi!e the$e a$e ommo%a!ities bet'ee% this ommu%i atio% o%te8t a%d the ommu%i atio% $e*ui$ed #o$ e%&a&i%& 'ith )$o(ide$ > )$o(ide$ o%#!i t, these o#te% i%(o!(e (e$" di##e$e%t t")es o# o%(e$satio%s, #o us o% di##e$e%t issues, a%d situate the )a$ti i)a%ts i% di##e$e%t $o!es- This di##e$e% e i% #o us has im)!i atio%s #o$ o%#!i t ma%a&eme%t t$ai%i%&s that use ommu%i atio% ou$ses e%te$ed o% )atie%t > )$o(ide$ i%te$a tio%s as the (e%ue a%d )oi%t o# a ess #o$ o%#!i t ma%a&eme%t-

+- Ad(e$se Out omes a%d Dis !osu$e

Dis !osu$e a%d t$a%s)a$e%t $es)o%ses to ad(e$se out omes a$e )$omi%e%t e8am)!es o#

o%#!i t e%&a&eme%t

)$i% i)!es a%d s"stems im)!eme%ted i% hea!th a$e- Mo(eme%ts ad(o ati%& )$oa ti(e $es)o%ses to ad(e$se out ome e(e%ts i%itia!!" a$ose #$om outside o# the hea!th )$o#essio%s- Ad(e$se out ome dis !osu$e be ame !ose!" o%%e ted 'ith the eme$&e% e o# the mode$% )atie%t sa#et" mo(eme%t i% the US, s)u$$ed b" a 0???

57 Ca$o! +- Liebma% a%d Ch$is Ste$% H"ma%, Medical "rror %isclosure- Mediation S!ills- and Malpractice Litigation) %emonstration Pro6ect in Pennsylvania, E2331F, htt):GG'''-)e't$usts-o$&Gou$M'o$4M$e)o$tMdetai!-as)8IidW2=;?A, Ea essed 0? Ma" 2303F: 03A58 59
Liebma% a%d H"ma%, Medical "rror %isclosure- Mediation S!ills- and Malpractice Litigation- 03@Liebma% a%d H"ma%, Medical "rror %isclosure- Mediation S!ills- and Malpractice Litigation- 03@-

;0

I%stitute o# Medi i%e Re)o$t o% the )$e(a!e% e o# ad(e$se medi a! e(e%ts- <3 Toda", dis !osu$e o# e$$o$s a%d u%a%ti i)ated out omes is a e%t$a! om)o%e%t o# the )atie%t sa#et" mo(eme%t but $emai%s !ose!" !i%4ed 'ith hea!th a$e dis)ute $eso!utio% mo$e b$oad!"<0

.hi!e it is 'ide!" $e o&%i5ed that mista4es o u$ i% the om)!e8 s"stem o# o%tem)o$a$" hea!th a$e, the s a!e o# i% ide%ts is sta&&e$i%&- The I%stitute #o$ Hea!th a$e Im)$o(eme%t estimates the$e a$e 01 mi!!io% i% ide%ts o# medi a! ha$m i% the US ea h "ea$, o$ a))$o8imate!" =3,333 )e$ da", i% !udi%& u) to 033,333 )$e(e%tab!e deaths a%%ua!!" i% US hos)ita!s- <2 The )ush #o$ t$a%s)a$e% " a%d dis !osu$e 'ith this (o!ume o# i% ide%ts has hu&e im)!i atio%s #o$ the dis)ute $eso!utio% #ie!d-

A t$aditio%a! $es)o%se to ad(e$se out omes has o#te% bee% ha$a te$i5ed as Bde%" a%d de#e%d-C Commu%i atio%s 'ith )atie%ts a%d #ami!ies a$e st$ate&i a%d de#e%si(e, a )ostu$e eme$&i%& #$om the be!ie# that the best )$ote tio% a&ai%st !iti&atio% i% the o%te8t o# a% ad(e$se e(e%ts is to sa" as !itt!e as )ossib!e to the )atie%t a%d #ami!" membe$s-<; This mode! see4s to a(oid dis !osu$e i# )ossib!e, $e o&%i5i%& that most )atie%ts %e(e$ dis o(e$ ases o# medi a! e$$o$-<= I% this #$ame'o$4, )$oa ti(e!" dis !osi%& medi a! e$$o$s to )atie%ts a%d a 4%o'!ed&i%& a $o!e i% them 'as see% as a hi&h6$is4 e%dea(o$ that 'ou!d o)e% the #!ood&ate to i% $eased !iti&atio% !aims- Ma%" mo$e )atie%ts 'ou!d sue #o$ e(e%ts that othe$'ise %e(e$ 'ou!d ha(e bee% $e o&%i5ed as medi a! e$$o$ b" the )atie%t- Fu$the$, b" a 4%o'!ed&i%& a $o!e i% the ad(e$se e(e%t

60 L-T- Joh%, et a!-, To "rr is (uman) 4uilding a Safer (ealth System- .ashi%&to%, D-C-: Natio%a! A adem" P$ess, 233361 The ommu%i atio% a%d dis !osu$e a ti(ities su$$ou%di%& ad(e$se out omes both uti!i5e o%#!i t ma%a&eme%t s4i!!s a%d )$o esses as 'e!! as $eate o%#!i ts that #eed i%to su))o$ti%& o%#!i t ma%a&eme%t st$u tu$es #o$ a $es)o%se- See Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t, %isclosure of Unanticipated "vents) Creating an "ffective Patient Communication Policy EChi a&o: Ame$i a% Hos)ita! Asso iatio%, No(embe$ 233;F: A- htt):GG'''-ash$m-o$&Gash$mGedu atio%Gde(e!o)me%tGmo%o&$a)hsG Ea essed 01 Ma" 2303F62 Ha$$" Ma5adoo$ia%, BADR a%d Hea!th Ca$e: A% O(e$(ie',C %ispute Resolution Maga&ine 0<, %o- ; ES)$i%& 2303F: =63 Ch$is Ste$% H"ma% a%d Ca$o! Liebma%, BMediati%& Medi a! Ma!)$a ti e La'suits: The Need #o$ P!ai%ti## a%d Ph"si ia% Pa$ti i)atio%,C %ispute Resolution Maga&ine 0<, %o- ; ES)$i%& 2303F: @64 Da(id Studde$t, et a!-, BDis !osu$e o# Medi a! I%Du$" to Patie%ts: A% Im)$obab!" Ris4 Ma%a&eme%t St$ate&",C (ealth ffairs 2<, %o- 0 E/a%ua$"GFeb$ua$" 233@F: 201622<;2

Ee(e% i# %ot admitti%& #au!tF 'ou!d i% $ease the !i4e!ihood that sett!eme%ts 'ou!d #a(o$ the )!ai%ti##-<1 As a $esu!t o# these be!ie#s, )$o(ide$s 'e$e ad(ised %ot to dis !ose i%#o$matio% to the )atie%t a%d t")i a!!" a!! #i%di%&s #$om i%(esti&atio%s 'e$e 4e)t se $et- Co%(e$satio%s bet'ee% )$o(ide$ a%d )atie%t about the i% ide%t 'e$e dis ou$a&ed i# %ot )$ohibited-

Ma%" 'e$e dissatis#ied 'ith this a))$oa h, 'hi h #$e*ue%t!" !ead to a dest$u ti(e a%d u%satis#"i%& )atte$% o# se $e ", dist$ust, a%d )oo$ ommu%i atio%- Ea$!" dis !osu$e )$o&$ams 'e$e attem)ts to b$ea4 the #o!!o'i%& ommo% " !e : a% u%a%ti i)ated ad(e$se medi a! out ome #ai!s to meet the e8)e tatio%s o# a )atie%t7 the )h"si ia%, eithe$ o% i%st$u tio% #$om !e&a! ou%se! o$ due to thei$ o'% de%ia! about the u%a%ti i)ated out ome, ommu%i ates mi%ima!!" i# at a!! 'ith the )atie%t7 the )atie%tG)$o(ide$ $e!atio%shi) disi%te&$ates7 the )atie%t &$o's i% $easi%&!" #$ust$ated b" o%ti%ued u%su ess#u! attem)ts to &et i%#o$matio%7 the #$ust$atio% a%d !a 4 o# i%#o$matio% e(o!(es i%to a%&e$7
<<

the a%&e$ a%d mist$ust, i# u%add$essed, !eads to a medi a! ma!)$a ti e !aim- The $esu!ti%& emotio%a! a%d #i%a% ia! dama&e is si&%i#i a%t, a##e ti%& both )$o(ide$ a%d )atie%t-

Usi%& $esea$ h that su&&ested !iti&atio% is mo$e !i4e!" 'he% )atie%ts a%d #ami!ies #ee! the" ha(e %ot $e ei(ed a%s'e$s to thei$ *uestio%s,<@ )$o(ide$s, hos)ita!s, a%d i%su$e$s be&a% )$omoti%& mo$e o)e%, ho%est ommu%i atio% 'ith )atie%ts a%d thei$ #ami!ies #o!!o'i%& ad(e$se out omes- Ea$!" $esea$ h hi&h!i&hted that emotio%a! t$auma #$om a se$ious ad(e$se e(e%t o#te% a$ises #$om both the e(e%t a%d the 'a" that it is

65 Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t, %isclosure of Unanticipated "vents) The .e#t Step in 4etter Communication EChi a&o: Ame$i a% Hos)ita! Asso iatio%, 233;F, htt):GG'''-ash$m-o$&Gash$mGedu atio%Gde(e!o)me%tGmo%o&$a)hsG Ea essed 01 Ma" 2303F: <6@66 Thomas Ga!!a&he$ a%d Ri he$t Sui%%, B.hat to do 'ith the U%a%ti i)ated Out ome,C )a)e$ )$ese%tatio% at Medical Liability and (ealth Care Law Seminar EDRI > Ma$ h 233<, Phoe%i8, A$i5o%aFhtt):GG'''-'(mi - omG$is4ma%a&eme%tG a$e6)$o&$am-)h) Ea essed 01 Ma" 2303F: 0=067 Ge$a!d Hi 4so%, E!!e% C!a"to%, Pe%%" Githe%s, a%d F$a%4 S!oa%, BFa to$s that P$om)ted Fami!ies to Fi!e Medi a! Ma!)$a ti e C!aims Fo!!o'i%& Pe$i%ata! I%Du$ies,C $ournal of the merican Medical ssociation 2<@, %o- 03 E0??2F: 0;1?6<;7 .e%d" Le(i%so%, et a!-, BPh"si ia%6Patie%t Commu%i atio%: The Re!atio%shi) 'ith Ma!)$a ti e C!aims amo%& P$ima$" Ca$e Ph"si ia%s a%d Su$&eo%s,C $ournal of the merican Medical ssociation 2@@, %o- @ E0??@F: 11;611?7 Ge$a$di, BThe Cu!tu$e o# Hea!th a$e-C
;;

ha%d!ed b" the )$o(ide$, i%su$e$, a%d hos)ita!-

<A

I%se%siti(e ma%a&eme%t o# the situatio% a% !ead to &$eate$

emotio%a! dama&e, 'hi!e se%siti(it", t$a%s)a$e% ", &ood ommu%i atio%, a%d e##e ti(e $es)o%ses to the )atie%t9s %eeds a% $edu e emotio%a! t$auma<?

Thou&h o% e$%s 'ith !iti&atio% $emai%ed, this a))$oa h 'as see% to bette$

meet the %eeds o# )atie%ts a%d a!i&% mo$e !ose!" 'ith 'hat the )$o(ide$s #e!t 'as $i&ht-

The su))o$t #o$ a shi#t i% st$ate&" ame #$om a (a$iet" o# sou$ es- The$e 'as a st$o%& mo$a! a$&ume%t that t$a%s)a$e% " a%d o)e% ommu%i atio% 'as a $e*ui$eme%t o# the )$o#essio%a! ethi s o# hea!th a$e )$o(ide$s- F$om a $is4 ma%a&eme%t )e$s)e ti(e, i%itia! su))o$t #o$ dis !osu$e ame #$om data su&&esti%& that !iti&atio% o#te% $esu!ts #$om the 'a" that a% u%a%ti i)ated out ome is ha%d!ed $athe$ tha% the i% ide%t itse!#-@3 Ea$!" e%thusiasm #o$ this idea, ou)!ed 'ith the ethi a! a$&ume%t behi%d the )$i% i)!e o# t$a%s)a$e% " a%d o))o$tu%ities #o$ im)$o(i%& )atie%t sa#et" th$ou&h a $obust #eedba 4 !oo), he!)ed mai%st$eam dis !osu$e )$a ti es-

As the o$ie%tatio% to'a$ds t$a%s)a$e% " a%d dis !osu$e has &a$%e$ed ad(o ates 'ithi% the hea!th a$e #ie!d, it has estab!ished a disti% t te$mi%o!o&"- T'o de#i%itio%s i%t$odu ed b" the Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t i% 233; $emai% 'ide!" i% use:
@0

Ad1erse E1ent: A% i%Du$" that 'as aused b" medi a! ma%a&eme%t $athe$ tha% the )atie%t9s

68 Ga!!a&he$, et a!-, BPatie%ts9 a%d Ph"si ia%s9 Attitudes Re&a$di%& the Dis !osu$e o# Medi a! E$$o$s,C $ournal of the merican Medical ssociation 2A?, %o- A E233;F:03306@7 Cha$!es Li% e%t, Ma&&ie Xou%&, a%d A%&e!a Phi!!i)s, B.h" do )eo)!e sue do to$sI A stud" o# )atie%ts a%d $e!ati(es ta4i%& !e&a! a tio%,C The Lancet ;=; E0??=F:0<3?>0<0=69 Ga!!a&he$, et a!-, BPatie%ts9 a%d Ph"si ia%s9 Attitudes-C7 Li% e%t, Xou%&, a%d Phi!!i)s- B.h" do )eo)!e sue do to$sIC7 Cha$!es Li% e%t, BU%de$sta%di%& a%d $es)o%di%& to ad(e$se e(e%ts,C .ew "ngland $ournal of Medicine- ;=A E233;F: 0310><Li% e%t, Xou%&, a%d Phi!!i)s- B.h" do )eo)!e sue do to$sIC Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t, %isclosure of Unanticipated "vents) Creating an "ffective Patient Communication Policy EChi a&o: Ame$i a% Hos)ita! Asso iatio%, 233;F htt):GG'''-ash$m-o$&Gash$mGedu atio%Gde(e!o)me%tGmo%o&$a)hsG Ea essed 01 Ma", 2303F7 see a!so Ha$(a$d Hos)ita!s, ,hen Things Go ,rong) Responding to dverse "vents+ Consensus Statement of the (arvard (ospitals, E+osto%, MA: Massa husetts Coa!itio% #o$ the P$e(e%tio% o# Medi a! E$$o$s, Ma$ h 233<Fhtt):GG'''-ma oa!itio%-o$&Gdo ume%tsG$es)o%di%&ToAd(e$seE(e%ts-)d# Ea essed 01 Ma" 2303F:

70 71

5.
;=

u%de$!"i%& disease7 a!so $e#e$$ed to as a% i% ide%t, ad(e$se out ome o$ u%a%ti i)ated out ome- A% ad(e$se e(e%t ma" o$ ma" %ot $esu!t #$om a% e$$o$- Medi a! ma%a&eme%t $e#e$s to a!! as)e ts o# hea!th a$e, %ot Dust the a tio%s o$ de isio%s o# )h"si ia%s o$ %u$ses-

#isclosure: P$o(idi%& i%#o$matio% to a )atie%t a%dGo$ #ami!" about a% i% ide%t- The Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t a%d othe$s su&&est B ommu%i atio%C as the )$e#e$$ed te$m mo(i%& #o$'a$d, stati%&, BUsi%& the 'o$d Bdis !osu$eC a% o#te% &i(e the im)$essio% that the o%se*ue% es o# %ot ha(i%& su h a )o!i " 'ou!d i%di ate B%o%6dis !osu$e-C I%stead, usi%& )$oa ti(e te$ms su h as B ommu%i atio%C ma" a(oid this im)$essio% a%d o%(e" a )ositi(e u!tu$a! stateme%t-C@2 Ho'e(e$, at )$ese%t dis !osu$e $emai%s the most 'ide!" uti!i5ed te$m-

The$e is (a$iatio% i% 'hat i%stitutio%s ate&o$i5e as a% ad(e$se e(e%t-@; .hi!e some i%stitutio%s use $est$i ti(e de#i%itio%s su h as that !isted abo(e, othe$s, su h as Jaise$ Pe$ma%e%te, ado)t a% e8)a%si(e de#i%itio% that t$i&&e$s thei$ Hea!th Ca$e OmbudsGMediato$ s"stem a%" time the )atie%t is %ot satis#ied-@=

This b$oade%ed de#i%itio% is i% !i%e 'ith the o$ie%tatio% to'a$ds o%ti%uit" i% se$(i es a%d im)$o(ed ommu%i atio% bet'ee% )$o(ide$s a%d )atie%ts th$ou&hout a!! i%te$a tio%s-

The u!tu$e o# the hea!th a$e i%dust$" o%ti%ues to shi#t to'a$ds ado)ti%& )$oa ti(e dis !osu$e, t$a%s)a$e%t ommu%i atio%, a%d em)atheti , )atie%t6 e%te$ed $es)o%ses to ad(e$se out omes as the )$o#essio%a! a%d ethi a! dut" o# hea!th a$e )$o(ide$s- Dis !osu$e )o!i ies a$e bei%& ad(o ated a%d i% $easi%&!" im)!eme%ted b" )$o(ide$s a%d $is4 ma%a&e$s, i%su$e$s a%d hos)ita!s, a%d $e&u!atio% a%d a $editatio% bodies-

72 Fo$ additio%a! omme%ts o% the t$e%d to'a$ds usi%& the te$m ommu%i atio% i%stead o# dis !osu$e, see Ha$(a$d Hos)ita!s, ,hen Things Go ,rong- @Ha$(a$d Hos)ita!s, ,hen Things Go ,rong- =Autho$ te!e)ho%e i%te$(ie' 'ith Jath!ee% Ne!so%, Natio%a! Leade$, Patie%t U Fami!" Ce%te$ed Ca$e U Hea!thCa$e Ombudsma%GMediato$, Patie%t Sa#et" U Ris4 Ma%a&eme%t, Jaise$ Pe$ma%e%te, 0= Ma" 2303-

73 74

;1

Thou&h the i% $easi%& o%se%sus o% the %eed #o$ dis !osu$e, the$e $emai% di##e$e% es i% )e$s)e ti(e o% the u!timate Dusti#i atio%s #o$ ado)ti%& #u!!6dis !osu$e )o!i ies-

Chi!d$e%9s Hos)ita!s a%d C!i%i s i% Mi%%ea)o!is@1 i%stitutio%a!i5ed a )o!i " o# #u!!6dis !osu$e to:

1 Im)$o(e )atie%t a%d sta## sa#et" b" de $easi%& s"stem (u!%e$abi!it" to #utu$e a ide%ts 2 Im)$o(e a$e )$o(ided 3 Resto$e )atie%t, #ami!", em)!o"ee, )$o(ide$, a%d ommu%it" o%#ide% e that s"stems a$e
i% )!a e to assu$e #utu$e a ide%ts a$e %ot !i4e!" to $e u$

4 Emotio%a!!", )$o#essio%a!!", a%d !e&a!!" su))o$t sta## 'ho ha(e bee% i%(o!(ed i% e(e%ts 5
E%su$e dis !osu$e o# the a ide%t, %ea$ miss, o$ se%ti%e! e(e%t to the #ami!", as 'e!! as o%&oi%&

ommu%i atio% o# s"stem im)$o(eme%ts to #ami!" a%d a$e&i(e$s i%(o!(ed i% the a ide%t

The So$$" .o$4sY Cam)ai&% o$ie%ts #u!! dis !osu$e to'a$ds the #o!!o'i%& out omes: @<

1 P$o(ide s'i#te$ Dusti e #o$ (i tims 2 Redu e medi a! e$$o$s 3 Resto$e the do to$6)atie%t $e!atio%shi) 4 Im)$o(e ommu%i atio% a%d t$ust bet'ee% a!! )a$ties 5 Re)ai$ the $e)utatio% o# do to$s a%d hos)ita!s b" tu$%i%& them i%to Bst$ai&ht shoote$sC
'ho a% be be!ie(ed 'he% the" sa" a death o$ i%Du$" 'as%9t thei$ #au!t

6 Redu e the #i!i%& o# %o%6me$ito$ious !aims th$ou&h the Bho%est" di(ide%dC 7 Add$ess the $oot auses o# medi a! ma!)$a ti e !aims

75

/u!ie Mo$ath a%d Te$$" Ha$t, BPa$t%e$i%& 'ith #ami!ies: dis !osu$e a%d t$ust,C )a)e$ )$ese%ted at .ational

Patient Safety 7oundation8 $C (* Patient Safety 'nitiative 2999) Spotlighting Strategies- Sharing Solutions EO tobe$ <, 23337 Chi a&o, ILF, htt):GG'''-%)s#-o$&Gdo'%!oadGMo$ath-)d#- Ea essed 0= Ma" 2303F-

76 Dou& .oD ies5a4, /oh% +a%Da, a%d Ca$o!e Hou4, BThe So$$" .o$4sY Coa!itio%: Ma4i%& the Case #o$ Fu!! Dis !osu$e,C $oint Commission $ournal on /uality and Patient Safety ;2, %o- < E/u%e 233<F7 ;==6;=<;<

.hi!e these 'ide!"6 ited be%e#its o# dis !osu$e a%d t$a%s)a$e% " ha(e he!)ed to s)$ead the mo(eme%ts, the

u!timate Dusti#i atio% #o$ #u!!6dis !osu$e o%ti%ues to $est i% ethi a! a$&ume%ts- Jaise$ Pe$ma%e%te as a%
i%stitutio% states that it )$omotes dis !osu$e be ause Bit is the $i&ht thi%& to do-C@@ The Co%se%sus Stateme%t
o# the Ha$(a$d Hos)ita!s e hoes this, 'ith Dusti#i atio% #o$ the shi#t $esti%& o% a mo$a! a$&ume%t, $athe$ tha%

a busi%ess ase, a!thou&h the be%e#its o# i% $eased t$ust a%d )$omotio% o# )atie%t sa#et" 'e$e a!so %oted-@A
The Da$tmouth Medi a! S hoo! Ha%dboo4 o% Ru$a! Medi i%e $e#e$e% es the ethi a! )$i% i)!es u%de$!"i%&

the medi a! )$o#essio% #o$ a mo$e e8)!i it e8)!a%atio% o# 'h" 'e #ee! dis !osu$e is the B$i&ht thi%& to do-C @?

I% the e%d, it is the ethi a! #o$ e o# dis !osu$e that is the ba 4bo%e o# this mo(eme%t-

The$e a$e simi!a$ disa&$eeme%ts about ho' to de#i%e a%d measu$e su

/CAHO Sta%da$ds o% A a

ess#u! dis !osu$e- I% 2330, the

$editatio% be&a% $e*ui$i%& i%stitutio%s to ha(e a dis !osu$e )o!i " to *ua!i#" #o$

$editatio%- This si&%i#i a%t!" bo!ste$ed the dis !osu$e mo(eme%t- The Sta%da$ds, ho'e(e$, ha(e %e(e$

de#i%ed su ess#u! dis !osu$e- As a $esu!t, de#i%itio%s o# a su ess#u! dis !osu$e o%(e$satio% (a$" a%d

i% !ude:A3

1 The )atie%t a%d #ami!" do %ot sue 2 The )atie%t a%d #ami!" u%de$sta%d that mista4es ha))e% a%d do %ot &et a%&$" 3 The )atie%t a%d #ami!" do%9t &o to the )$ess

@@

T$a e" .a!4e$, BAd(o a " 'ith om)assio%: Do$oth" Ta$$a%t9s $o!e as hea!th a$e ombudsma%Gmediato$ )!a es he$ at the %e8us o# )atie%t6)$o(ide$ i%te$a tio%,C Managed (ealthcare "#ecutive E/u%e 0, 233<F, htt):GGma%a&edhea!th a$ee8e uti(e-mode$%medi i%e- omGmheGLisio%a$iesGAd(o a "6'ith6 om)assio%6 Do$oth"6Ta$$a%ts6$o!e6as6GA$ti !eSta%da$dGA$ti !eGdetai!G;2??21 Ea essed 01 Ma" 2303F7 /oi%t Commissio% o% Hea!th Ca$e EState o# Li$&i%iaF, 0arious Responses to Medical "rror) Report %ocument .o+ :9; ERi hmo%d, LA: Commo%'ea!th o# Li$&i%ia, 233?F: <?B.he% hea!th a$e )$o(ide$s do %ot $e o&%i5e, $e)o$t, o$ dis !ose e$$o$s, the" #ai! to a t i% the best i%te$est o# the )atie%t- This #ai!u$e om)$omises )atie%t auto%om" a%d i%#o$med de isio%6ma4i%&- The #ai!u$e to $e)o$t a%d dis !ose e$$o$s a!so om)$omises the )$i% i)!es o# be%e#i e% e, #ide!it", a%d Dusti e, dis ussed i% detai! i% Cha)te$ ; o# this (andboo!-C A%% F$eema% Coo4 a%d He!e%a Hoas, BEthi s Co%#!i ts i% Ru$a! Commu%ities: Re o&%i5i%& a%d Dis !osi%& Medi a! E$$o$s,C i% (andboo! for Rural (ealthcare "thics- .i!!iam A- Ne!so%, edET$ustees o# Da$tmouth Co!!e&e: Ha%o(e$, NH, 233?F, htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG ha)te$6 02-)d# Ea essed 0= Ma" 2303F: 2;<-

78 79

Ha$(a$d Hos)ita!s, ,hen Things Go ,rong- ;-

80

Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t, %isclosure of Unanticipated "vents- <6@-

;@

1 The )$ess )$aises the a$e&i(e$s9 a tio% a%d ho%est"

Fo$ the bottom !i%e, s4e)ti s Eas 'e!! as ma%" adhe$e%tsF o#te% !oo4 to the #i%a% ia! osts a%d be%e#its o# im)!eme%ti%& a )$oa ti(e dis !osu$e )$o&$am $e!ati(e to othe$ )$o&$ams that do %ot )$omote #u!!6dis !osu$e-

The Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t, i% a% i%#!ue%tia! 233; mo%o!o&ue, di$e t!"
o%tested measu$eme%ts o# su ess based u)o% se!#6se$(i%& out omes- The" a$&ued that su h #$ame'o$4s

miss the )oi%t:A0 It #ai!s to $e o&%i5e the t$ue )u$)ose o# dis !osu$e: the o)e% ommu%i atio% about a!! as)e ts o# a$e 'ith )atie%ts a%d #ami!ies- A su ess#u! dis !osu$e )$o ess ou!d best be des $ibed as o%e that e%ab!es the )atie%t a%d #ami!" to u%de$sta%d 'hat ha))e%ed a%d the $ami#i atio%s o# the e(e%t as 'e!! as ha(e su##i ie%t i%#o$matio% to ma4e #utu$e de isio%s:-The t$ue su ess o# dis !osu$e a% o%!" be measu$ed i% the e##i a " o# ommu%i ati%& #a ts a%d sha$i%& $e&$et #o$ the )atie%t9sG#ami!"9s t$aumaIm)o$ta%t!", the mo%o!o&ue o%ti%ues 'ith a (isio% #o$ a% im)$o(ed )atie%t > )$o(ide$ $e!atio%shi) i% the

#utu$e:
I% the s)i$it o# im)$o(i%& )atie%t sa#et" a%d $eati%& a B!ea$%i%& o$&a%i5atio%,C it 'ou!d he!) to thi%4 o# a!! dis !osu$e ommu%i atio%s as o))o$tu%ities #o$ im)$o(i%& ommu%i atio% 'ith )atie%ts at a!! )oi%ts o# the hea!th a$e o%ti%uum- I# hea!th a$e )$o(ide$s a% &et to the )!a e 'he$e the" be&i% thei$ $e!atio%shi)s 'ith )atie%ts ta!4i%& about the )ote%tia! #o$ e$$o$ a%d the %eed #o$ i%te$a ti(e ommu%i atio% a%d )a$t%e$shi), the sta&e a% be set #o$ mo$e e##e ti(e i%te$a tio% shou!d the %eed #o$ the dis !osu$e o# a% u%a%ti i)ated e(e%t a$iseThis #o us o% $es)e t, a ess to i%#o$matio%, a%d )a$t%e$shi) 'as a )$e u$so$ to u$$e%t a!!s #o$ sha$ed

de isio% ma4i%&, i% $eased ommu%i atio%, a%d $e(am)ed )atie%t6)$o(ide$ $e!atio%shi)s-

Criti<ues of %isclosure

A0

Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t, %isclosure of unanticipated events) the ne#t step in better communication =part one of three> EChi a&o: Ame$i a% Hos)ita! Asso iatio%, No(embe$ 233;F: ?, 03htt):GG'''-ash$m-o$&Gash$mGedu atio%Gde(e!o)me%tGmo%o&$a)hsG Ea essed 01 Ma" 2303F-

;A

.hi!e the hea!th a$e u!tu$e a%d its a

om)a%"i%& )o!i ies a%d $e&u!atio%s i% $easi%&!" ado)t #u!!

dis !osu$e o# ad(e$se out omes as the %o$mati(e sta%da$d o# )$a ti e #o$ hea!th a$e )$o(ide$s, i%su$a% e om)a%ies, a%d hos)ita!s, *uestio%s $emai%- A 233@ stud" b" Studde$t, et a!- usi%& mathemati a! mode!i%& su&&ested that #u!! dis !osu$e o# medi a! e$$o$ 'ou!d !i4e!" &$eat!" i% $ease the %umbe$ o# !aims a%d ost o# $eimbu$seme%t-A2 .hi!e the a$ti !e ad(o ated #o$ dis !osu$e as best )$a ti e due to ethi a! $easo%s, it )$edi ted that dis !osu$e 'ou!d $eate si&%i#i a%t #i%a% ia! bu$de%s i# ado)ted 'ide!"- C$iti s o# the $esea$ h de%ied this a%d a!!ed #o$ #u$the$ $esea$ h o% the a tua! !aim i% $eases a%d ost bu$de% e8)e$ie% ed b" hos)ita!s a%d i%su$a% e om)a%ies 'ho ha(e i%stituted dis !osu$e )o!i ies-A; Re e%t data o%ti%ues to su&&est that the )$edi ted E#ea$edF ost bu$de% has %ot mate$ia!i5edA= #o$ i%stitutio%s im)!eme%ti%& dis !osu$e )o!i ies, but mo$e $esea$ h o% the subDe t is desi$ed-A1

.hi!e the ethi a! a$&ume%t i% su))o$t o# dis !osu$e is $a$e!" o%tested, $esista% e to im)!eme%ti%& #u!!6 dis !osu$e )$o&$ams $emai%s- ADR )$a titio%e$s o%ti%ue to ite ba$$ie$s to usi%& dis !osu$e a%d othe$ )atie%t6 e%te$ed $es)o%ses to ad(e$se out ome e(e%ts as o%(e%tio%a! 'a"s o# thi%4i%&, u%Dusti#ied #ea$, a%d i%stitutio%a! a%d )$o#essio%a! u!tu$es-A< Ph"si ia%s $emai% o% e$%ed 'ith bei%& $e)o$ted to !i e%si%&

82 Da(id Studde$t, et a!-, BDis !osu$e o# Medi a! I%Du$" to Patie%ts: A% Im)$obab!" Ris4 Ma%a&eme%t St$ate&",C (ealth ffairs 2<, %o- 0 E/a%GFeb 233@F: 201622<83 Ste(e J$ama% a%d Gi%%" Hamm, B+ad Mode!i%&,C (ealth ffairs 2<, %o- ; EMa"G/u%e 233@F: ?3;7 /oh% .a4e#ie!d, Ch$isti%e /o$m, a%d Che$ie R"a%, BO)e% Dis !osu$e: Detai!s Matte$,C (ealth ffairs 2<, %o- ; EMa"G/u%e 233@F: ?3;7 So$$" .o$4sY Coa!itio%, Sorry ,or!s? Reply to (arvard %isclosure Study, htt):GG'''-so$$"'o$4s-%etGa$ti !e=@-)htm! Ea essed 01 Ma" 2303F84 Je!!" Sa$a%, BThe U%i(e$sit" o# Mi hi&a% C!aims E8)e$ie% e: Dis !osu$e, Commu%i atio%, a%d Patie%t Sa#et",C )o'e$)oi%t )$ese%tatio% at C PS C nnual Convening- pril 19- 29:9htt):GG'''- a)sa -o$&Gdo ume%tsGSa$a%-J-)d# Ea essed 0= Ma" 2303F Qsho'i%& #ea$ed ost bu$de% has %ot mate$ia!i5edR7 Ri he$t Sui%%, BCo)i 9s ;Rs P$o&$am: Re o&%i5e, Res)o%d to, a%d Reso!(e Patie%t I%Du$",C )o'e$)oi%t )$ese%tatio%, htt):GG'''-so$$"'o$4s-%etG o)i -)htm! Ea essed 0= Ma" 2303F Qsee s!ide ;3, sho'i%& a tua! $eimbu$seme%ts #o$ !aims ha%d!ed th$ou&h dis !osu$e )$oto o!s 'e$e o%!" =0K o# the $eimbu$seme%t (a!ues )$edi ted b" !aims adDuste$s7 i%di ates !o'e$ $eimbu$seme%t )e$ !aim but does %ot sho' ho' ma%" mo$e !aims the" $e ei(eR7 Ga!!a&he$ a%d Sui%%, B.hat to do 'ith the U%a%ti i)ated Out ome,C 0=2 Q233; COPIC $esu!ts sho'ed that !oss $atios #o$ )h"si ia%s )a$ti i)ati%& i% the )$o&$am 'e$e 21K !ess tha% #o$ those %ot )a$ti i)ati%& i% the )$o&$am, des)ite s!i&ht!" hi&he$ tha% a(e$a&e histo$i !oss $atios #o$ the )a$ti i)ati%& )h"si ia%s )$io$ to e%$o!!me%tR85 /oi%t Commissio% o% Hea!th a$e EState o# Li$&i%iaF, 0arious Responses to Medical "rror) Report %ocument .o+ :9; ERi hmo%d, LA: Commo%'ea!th o# Li$&i%ia, 233?F86
Liebma% a%d H"ma% BMediati%& Medi a! Ma!)$a ti e La'suits,C <-

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boa$ds a%d dama&i%& )$o#essio%a! $e)utatio%- Ma%" sta4eho!de$s $emai% o% the #e% e about dis !osu$e, a'aiti%& #u$the$ data- Fo$ )$a titio%e$s, the )ote%tia! #o$ dis !osu$e to $esto$e )ub!i t$ust i% the ho%est" a%d i%te&$it" o# the medi a! )$o#essio% a$e see% as st$o%& se!!i%& )oi%tsa%d ost o# !iti&atio% a$e im)o$ta%tAA A@

Fo$ $is4 ma%a&e$s, )atie%t satis#a tio% $ates a%d the $ates

Data, ase studies, a%d im)a t i%di ato$s measu$i%& these #a to$s a$e

es)e ia!!" (a!uab!e as dis !osu$e )$o&$ams see4 to e8)a%d a%d be sustai%ab!e-

Potential "#ploitation of %isclosure

Dis !osu$e )$o esses ha(e the )ote%tia! to be abused b" bad o$ u%de$6s4i!!ed do to$s- The )$i(ate %atu$e o# dis !osu$e o%(e$satio%s has the )ote%tia! to be ome )$ob!emati i# the !a 4 o# t$a%s)a$e% " a%d )ub!i a ou%tabi!it" a!!o's )h"si ia%s o$ hos)ita!s to h$o%i a!!" ommit medi a! e$$o$s- I# the t$aditio%a! a ou%tabi!it" me ha%ismsTa !a'suit o$ a !aim #i!ed 'ith the NCDM o$ MCE a&ai%st a )h"si ia%Ta$e %ot a ti(ated, the% it is o%!" i%te$%a! a to$s Ea% i%su$a% e om)a%" o$ the i%(o!(ed hea!th a$e i%stitutio%F i% the )ositio% to mo%ito$ )$ob!em )h"si ia%s a%d e%su$e that )h"si ia% o$ hos)ita! )$a ti es ha%&e i% $es)o%se to ad(e$se e(e%ts- I# )$o&$ams i%di ate )$ob!em )h"si ia%s a%d i%stitutio%s a$e e8)!oiti%& dis !osu$e o%(e$satio%s, it ma" be ome %e essa$" to ba!a% e the be%e#its o# o%#ide%tia!it" 'ith the %eed #o$ )h"si ia% mo%ito$i%& a%d o(e$si&ht-

The Role of pology

E8)$essio%s o# a)o!o&" b" hea!th a$e )$o(ide$s a$e !ose!" !i%4ed 'ith dis !osu$e o%(e$satio%s- A)o!o&ies usua!!" ta4e o%e o# t'o #o$ms- Fu!! a)o!o&ies a e)t $es)o%sibi!it" #o$ 'hat has t$a%s)i$ed: BI9m so$$", I did this to "ou,C is a% e8am)!e- Pa$tia! a)o!o&ies $e#e$ to a)o!o&ies o# s"m)ath" 'ithout admissio% o# $es)o%sibi!it" o$ #au!t: BI9m so$$" this ha))e%ed to "ou,C is a% e8am)!e- .hi!e it 'as t$aditio%a!!" assumed

87 Thomas Ga!!a&he$, Da(id Studde$t, a%d .e%d" Le(i%so%, BDis !osi%& Ha$m#u! Medi a! E$$o$s to Patie%ts,C .ew "ngland $ournal of Medicine ;1<, %o- 2< E233@F: 2@0;62@0?88
Ga!!a&he$, Studde$t, a%d Le(i%so%, BDis !osi%& Ha$m#u! Medi a! E$$o$s to Patie%ts,C 2@0;-

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that a )a$tia! a)o!o&" 'as bette$ tha% %o a)o!o&", $e e%t em)i$i a! e(ide% e su&&ests that is #a!se-

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studies su&&est that #u!! dis !osu$e has si&%i#i a%t )ositi(e im)a t o% )atie%t t$ust a%d thei$ )e$ e)tio%s o# the )h"si ia% a%d a% )!a" a% im)o$ta%t $o!e i% $esto$i%& the )atie%t6)h"si ia% $e!atio%shi)?3

.hi!e #u!! dis !osu$e )o!i ies t")i a!!" e% ou$a&e #u!! a)o!o&ies, ma%" i%stitutio%s, i%su$e$s, a%d )$o(ide$s sti!! o)e$ate dis !osu$e o%(e$satio%s u%de$ )$oto o!s that do %ot )e$mit o$ e% ou$a&e a$e )$o(ide$s to admit #au!t #o$ a% ad(e$se out ome- The )$ima$" ba$$ie$ to a)o!o&i5i%& is !iabi!it" o% e$%s- T$aditio%a!!", a)o!o&ies 'e$e admissib!e i% ou$t as e(ide% e o# '$o%&doi%& i% most Du$isdi tio%s- I% $easi%&!" this is ha%&i%&: as o# 233A, ;< states had e%a ted a)o!o&" !a's )$ote ti%& (o!u%ta$" dis !osu$es-?0 Ho'e(e$, 2A o# these !a's )$ote t o%!" )a$tia! a)o!o&ies, )$e(e%ti%& the admissio% o# e8)$essio%s o# s"m)ath", $e&$et, a%d o%do!e% e i% #utu$e !iti&atio% )$o eedi%&s a&ai%st a )h"si ia%- O%!" the $emai%i%& A !a's )$ote t admissio%s o# #au!t as 'e!!-?2 .hi!e !a's &o(e$%i%& the admissibi!it" o# a)o!o&ies i% t$ia!s a$e ha%&i%& to add$ess this o% e$%, the $e!u ta% e to admit #au!t #o$ #ea$ o# !iti&atio% $emai%s a si&%i#i a%t hu$d!e-

The $e!atio%shi) bet'ee% dis !osu$e a%d #u!! a)o!o&" admitti%& #au!t has %ot "et bee% sta%da$di5ed a $oss the mode!s me%tio%ed be!o'- Mu h o# the !ite$atu$e $e(ie'ed des $ibi%& the di##e$e%t dis !osu$e mode!s a%d )$o&$ams does %ot s)e i#" 'hat 4i%d o# a)o!o&" 'ith 'hat de&$ee o# admissio% o# #au!t is de!i(e$ed as )a$t o# the )$o&$am, 'ho has #i%a! autho$it" to de ide this, a%d the de&$ee o# a)o!o&" (a$iatio% a $oss s)e i#i dis !osu$e o%(e$satio%s- U%de$sta%di%& the e##e t o# di##e$e%t t")es o# a)o!o&" o% the out ome o# dis !osu$e o%(e$satio%s a%d medi a! ma!)$a ti e dis)utes $emai%s a to)i #o$ #u$the$ stud"-

89 /e%%i#e$ J- Robbe%%o!t, BA)o!o&ies a%d Le&a! Sett!eme%t: A% Em)i$i a! E8ami%atio%,C Michigan Law Review 032 E233;F: =<3610<90 Jath!ee% Ma5o$, et a!-, BHea!th P!a% Membe$s9 Lie's about Dis !osu$e o# Medi a! E$$o$s,C 'nternal Medicine 0=3 E233=F:=3?6=0Annals of

91 .i!!iam M- M Do%%e!! a%d E!isabeth Gue%the$, BNa$$ati(e Re(ie': Do State La's Ma4e It Easie$ to Sa" BI9m So$$"IC,C nnals of 'nternal Medicine 0=? E233AF: A0292 The situatio% is om)!i ated b" the #a t that some states Esu h as Le$mo%tF )$ote t o$a! a%d '$itte% stateme%ts di##e$e%t!"- Othe$ states ha(e mo(ed be"o%d (o!u%ta$" dis !osu$e to ma%date that hos)ita!s a%d )h"si ia%s i%#o$m )atie%ts 'he% a medi a! e$$o$ has !ed to a% ad(e$se out ome, thou&h these states )$ote t this ma%dato$" dis !osu$e #$om bei%& used as a% admissio% o# #au!t i% !iti&atio% )$o eedi%&s- See M Do%%e!! a%d Gue%the$, BNa$$ati(e Re(ie': Do State La's Ma4e It Easie$ to Sa" BI9m So$$"C,C A02=0

"ffects on (ealth Care Providers

Medi a! e$$o$s a%d ad(e$se out omes a% ha(e si&%i#i a%t %e&ati(e im)a ts o% the hea!th a$e )$o(ide$s $es)o%sib!e #o$ these e(e%ts- Medi a! e$$o$s a%d ad(e$se out omes a% be t$aumati e(e%ts that )!a e e%o$mous emotio%a!, )s" ho!o&i a!, a%d )$o#essio%a! st$ess o% )$o(ide$s, ma%" o# 'hom #ee! t$eme%dous $es)o%sibi!it" #o$ thei$ )atie%ts9 'e!!bei%&- Ad(e$se e(e%ts a% ause !i%i ia%s to doubt thei$ )$a ti e, #ea$ !e&a! a tio%s, #ea$ !osi%& thei$ !i e%se o$ Dob, a%d d$ead !osi%& the $es)e t o# thei$ )ee$s-?; The st$ess #$om su h t$auma a% $eate a to8i 'o$4 e%(i$o%me%t- St$ess a%d bu$%out, ommo% amo%&st hea!th a$e )$o(ide$s, ha(e i% $easi%&!" bee% asso iated 'ith subo)tima! attitudes a%d )$a ti es that !ead to o%#!i t a%d a% om)$omise )atie%t a$e a%d )atie%t sa#et"- To add$ess this, )$o&$ams that su))o$t !i%i ia%s a$e see% as im)o$ta%t as)e ts o# om)$ehe%si(e $es)o%ses to ad(e$se out omes a%d medi a! e$$o$s-

E8am)!es o# Dis !osu$e P$o&$ams

Re omme%datio%s #o$ ho' to o%du t dis !osu$e o%(e$satio%s a$e o#te% st$u tu$ed a$ou%d the o%#!i t ma%a&eme%t a%d mediatio% o% e)ts o# i%#o$matio% &athe$i%&, ide%ti#"i%& sta4eho!de$s, ommu%i ati%& the &oa!, a ti(e !iste%i%&, see4i%& a&$eeme%t, #i%di%& so!utio%s, e8)!o$i%& mutua! &ai%, a%d )a$ti i)ato$" de isio% ma4i%&-?= Dis !osu$e )$o&$ams uti!i5e these a))$oa hes i% (a$ious a$$a%&eme%ts- The #o!!o'i%& des $i)tio%s o# the So$$" .o$4sY Coa!itio%, the LA Hea!th S"stem, the COPIC ;Rs, a%d the Jaise$ Pe$ma%e%te )$o&$ams he!) e8ami%e the detai!s o# ho' dis !osu$e )$o&$ams a$e desi&%ed a%d #u% tio%-

Sorry ,or!s? Coalition

93 Susa% Ca$$, BDis !osu$e a%d A)o!o&": .hat9s Missi%&I Ad(a% i%& P$o&$ams that Su))o$t C!i%i ia%s,C Patient Safety and /uality (ealthcare EMa$ hGA)$i! 2303F- '''-)s*h- omGma$ ha)$i!62303G=126dis !osu$e6a%d6 a)o!o&"6'hats6missi%&-htm! Ea essed 01 Ma" 2303F94 Robe$t Che$$", Le%%" Ma$ us, a%d +a$$" Do$%, BRe)o$ti%& Ad(e$se E(e%ts to Patie%ts: A Ste)6b"6Ste) A))$oa h,C Physician "#ecutive $ournal of Medical Management EMa"G/u%e 2303F: =6?=2

The So$$" .o$4sY Coa!itio%, a% o$&a%i5atio% o# hea!th a$e )$o(ide$s, i%su$e$s, !a'"e$s, a%d )atie%t ad(o ates, )$omotes )o!i ies o# #u!! dis !osu$e a%d a)o!o&ies #o$ medi a! e$$o$, a om)a%ied 'ith u)#$o%t om)e%satio%- The sta%da$d So$$" .o$4sY )$oto o!, based o% the dis !osu$e )$o&$am de(e!o)ed at the De)a$tme%t o# Lete$a%s A##ai$s Hos)ita! i% Le8i%&to%, Je%tu 4", states:

I# a sta%da$d o# a$e 'as %ot met Eas sho'% b" a $oot ause a%a!"sisF i% a bad out ome o$ ad(e$se e(e%t, the )$o(ide$s Ea%d thei$ i%su$e$F shou!d a)o!o&i5e to the )atie%tG#ami!", admit #au!t, )$o(ide a% e8)!a%atio% o# 'hat ha))e%ed a%d ho' the hos)ita! 'i!! e%su$e that the e$$o$ is %ot $e)eated, a%d o##e$ om)e%satio%- ?1

I% this mode!, )!ai%ti##s a$e e% ou$a&ed to o%ta t a !e&a! $e)$ese%tati(e, 'ho a% a!so be )$ese%t #o$ the dis !osu$e o%(e$satio%s- Patie%ts a$e %ot as4ed to si&% a%" 'ai(e$s o# thei$ $i&ht to )u$sue !iti&atio% as a )$e o%ditio% to )a$ti i)atio% i% dis !osu$e- This is Dusti#ied o% the be!ie# that b" %ot as4i%& #o$ a 'ai(e$ o# thei$ $i&ht to sue, )atie%ts a$e mo$e !i4e!" to t$ust that the )$o ess is #ai$ a%d %othi%& is bei%& o(e$ed6u)- Fu$the$, some hos)ita!s su&&est that it is be%e#i ia! to 4%o' that !e&a! ou%se! has bee% o%su!ted, as it he!)s e%su$e the )atie%tG#ami!" is a'a$e o# thei$ $i&hts, a%" de isio%s $ea hed a$e 'ith #u!! 4%o'!ed&e o# the a!te$%ati(es, a%d )atie%tsG#ami!ies ha(e a $ea!isti u%de$sta%di%& o# !aims )$o esses-?< This a% be see% as a (o!u%ta$" ste) to mi%imi5e )o'e$ imba!a% es that a% o u$ i% the

'a4e o# a% ad(e$se out ome, 'he% )atie%ts a$e o#te% *uite (u!%e$ab!e- It is a!so be!ie(ed to $eate mo$e $obust a&$eeme%ts, !eadi%& to mo$e om)!ete $eso!utio%-

95 Dou& .oD ies5a4, /oh% +a%Da, a%d Ca$o!e Hou4, BThe So$$" .o$4sY Coa!itio%: Ma4i%& the Case #o$ Fu!! Dis !osu$e,C $oint Commission $ournal on /uality and Patient Safety ;2, %o- < E/u%e 233<F: ;==6;13O tobe$ 2@, 2331, E.ashi%&to%, DC: Lete$a%s Hea!th Admi%ist$atio%F, =7 Ste(e J$ama%, BLi tim Com)e%satio% 'ithout Liti&atio%: The Le8i%&to% E8)e$ie% e,C )o'e$)oi%t )$ese%tatio% a(ai!ab!e at htt):GG'''-so$$"'o$4s-%etGe8 itedmi hi&a%-)htm! Ea essed 01 Ma" 2303F-

96

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The Coa!itio% ad(o ates a th$ee6ste) dis !osu$e )$o ess-?@ Ste) O%e, i%itia! dis !osu$e i% the immediate a#te$math o# a% ad(e$se e(e%t, i%(o!(es a)o!o&", $e o&%itio% o# the )atie%t9s situatio%, a%d e8)$essi%& em)ath", aimi%& to $e6estab!ish t$ust a%d ommu%i atio% 'ith )atie%ts a%d #ami!ies- Ste) T'o, i%(esti&atio%, !oo4s at the detai!s o# the i% ide%t to dete$mi%e i# a sta%da$d o# a$e 'as b$ea hed- F$e*ue%t!" this is a om)!ished b" outside e8)e$ts to a(oid )e$ e)tio%s o# a o(e$6u)- Ste) Th$ee, $eso!utio%, i%(o!(es sha$i%& the $esu!ts 'ith the )atie%tG#ami!" a%d thei$ !e&a! ou%se!- I# the$e 'as a mista4e, the )$o(ide$Ghos)ita!Gi%su$e$ o%ti%ues th$ou&h the )$oto o! out!i%ed abo(e- I# the$e 'as %o mista4e, the" sha$e the $esu!ts o# the i%(esti&atio% a%d o%ti%ue to em)athi5e 'ith the )atie%t, but see4 to )$o(e thei$ i%%o e% e- No sett!eme%t is o##e$ed a%d a%" !iti&atio% is o%tested- The Coa!itio% des $ibes its a))$oa h as B om)assio% 'ith a ba 4bo%e-C ?A

0 (ealth System "#perience

The LA Hea!th S"stem #u!!6dis !osu$e mode! 'as o%e o# the #i$st i% the ou%t$"- It is !a$&e!" the ea$!" su ess o# this )$o&$am that !ed to the bi$th o# the dis !osu$e mo(eme%t i% the US- ?? The

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The LA a))$oa h to dis !osu$e disti%&uishes t'o t")es o# dis !osu$e, e8)!ai%ed he$e i% thei$ LA Dis !osu$e

Po!i ":030
E2F Dis !osu$e o# Ad(e$se E(e%ts- Fo$ the )u$)ose o# this Di$e ti(e, the )h$ase Bdis !osu$e o# ad(e$se e(e%tsC $e#e$s to the #o$th$i&ht a%d em)atheti dis ussio% o# !i%i a!!" si&%i#i a%t #a ts bet'ee% )$o(ide$s a%dGo$ othe$ LHA )e$so%%e! a%d )atie%ts o$ thei$ $e)$ese%tati(es about the o u$$e% e o# a% ad(e$se e(e%t that $esu!ted i% )atie%t ha$m, o$ ou!d $esu!t i% ha$m i% the #o$eseeab!e #utu$e- LA $e o&%i5es t'o t")es o# dis !osu$e o# ad(e$se e(e%ts:

(1)

C!i%i a! Dis !osu$e o# Ad(e$se E(e%ts- A% i%#o$ma! )$o ess #o$ i%#o$mi%& )atie%ts o$ thei$

$e)$ese%tati(es o# ha$m#u! ad(e$se e(e%ts $e!ated to the )atie%t9s a$e- I% a !i%i a! dis !osu$e, o%e o$ mo$e membe$s o# the !i%i a! team )$o(ides #a tua! i%#o$matio% to the e8te%t it is 4%o'%, e8)$esses o% e$% #o$ the )atie%t9s 'e!#a$e, a%d $eassu$es the )atie%t o$ $e)$ese%tati(e that ste)s a$e bei%& ta4e% to i%(esti&ate the situatio%, $emed" a%" i%Du$", a%d )$e(e%t #u$the$ ha$m- The !i%i a! dis !osu$e o# ad(e$se e(e%ts %eeds to be o%side$ed a $outi%e )a$t o# !i%i a! a$e, a%d %eeds to be made b" the atte%di%& o$ se%io$ )$a titio%e$, o$ desi&%ee-

(2)I%stitutio%a! Dis

!osu$e o# Ad(e$se E(e%ts- I% ases $esu!ti%& i% se$ious i%Du$" o$ death, o$ those

i%(o!(i%& )ote%tia! !e&a! !iabi!it", a mo$e #o$ma! )$o ess is %eeded- This )$o ess is a!!ed i%stitutio%a! dis !osu$e o# ad(e$se e(e%ts- I% a% i%stitutio%a! dis !osu$e the )atie%t o$ $e)$ese%tati(e a%d a%" #ami!" membe$s desi&%ated b" the )atie%t o$ $e)$ese%tati(e a$e i%(ited to meet 'ith i%stitutio%a! !eade$s a%d othe$s, as a))$o)$iate- A% a)o!o&" is made, a%d i%#o$matio% about om)e%satio% a%d )$o edu$es a(ai!ab!e to $e*uest om)e%satio% is )$o(ided, 'he% a))$o)$iate:-

The LA dis !osu$e s"stem is 'e!!6i%te&$ated 'ith estab!ished ha%%e!s #o$ $e)o$ti%&, $es)o%se,
do ume%tatio%, a%d #o!!o'6u)- A!thou&h the !e&a! o%te8t o# the &o(e$%me%t6$u% LA hea!th s"stem di##e$s

#$om that o# the )$i(ate hea!th s"stems, this has $e!ati(e!" !itt!e e##e t o% the e##i a " o# the dis !osu$e
)$o&$am a%d is %ot a ba$$ie$ to s)$eadi%& the LA s"stem su
Nume$ous a ademi

ess to %o%6&o(e$%me%t hea!th setti%&s-032

e%te$s a%d )$i(ate hos)ita!s ha(e used the LA Dis !osu$e Mode! 'ith simi!a$!" st$o%&

$esu!ts-03;

The C*P'C 1Rs Program

101

De)a$tme%t o# Lete$a%s A##ai$s, %isclosure of dverse "vents to Patients) 0( %irective 299@A9B;-

O tobe$ 2@, 2331 E.ashi%&to%, DC: Lete$a%s Hea!th Admi%ist$atio%F: ;6=-

102 Fo$ di##e$e% es i% the !e&a! e%(i$o%me%t su$$ou%di%& the LA hea!th s"stem (e$sus )$i(ate hea!th s"stems, see J$ama%, BLi tim Com)e%satio% 'ithout Liti&atio%C )o'e$)oi%t, s!ide 0A103 The U%i(e$sit" o# Mi hi&a% s"stem i% )a$ti u!a$ is #$e*ue%t!" ited as a% e8am)!e o# ho' e##e ti(e!" the LA Dis !osu$e mode! a% #u% tio% outside o# the &o(e$%me%t s"stem=1

COPIC I%su$a% e o# Co!o$ado, a )h"si ia% ma!)$a ti e i%su$e$ based i% De%(e$, 'as o%e o# the ea$!" i%su$e$s to ad(o ate #o$ )h"si ia% dis !osu$e i% ad(e$se out ome ases03=

.hi!e thei$ a))$oa h

uti!i5es ma%" #eatu$es #ou%d i% the So$$" .o$4sY Mode!, COPIC o%!" uses dis !osu$e o% ases be!o' Z;3,333 i% (a!ue a%d e8 !udes )!ai%ti##9s atto$%e"s #$om )a$ti i)atio%a%" o# the #o!!o'i%& ha(e o
031

Fu$the$, ases a$e i%e!i&ib!e i#

u$$ed: )atie%t death7 #o$ma! '$itte% dema%d #o$ om)e%satio% #i!ed7

summo%s a%d om)!ai%t !od&es7 atto$%e" i%(o!(eme%t7 $e*uest #o$ a tio% #$om state !i e%si%& boa$d7 o$ i% ide%ts i%(o!(i%& e$tai% %atio%a!!" $e o&%i5ed u%a e)tab!e out omes03<

Usua!!" the

$es)o%sib!e )h"si ia% !eads a )$i(ate dis !osu$e dis ussio% di$e t!" 'ith the )atie%tG#ami!", thou&h COPIC ma" a!so a$$a%&e a mediatio% sessio% 'ith a% e8te$%a! %eut$a!03@

Pa$ti i)ati%& )h"si ia%s a$e e8)e ted to atte%d a COPIC edu atio%a! semi%a$ add$essi%& )h"si ia%G)atie%t ommu%i atio%- Additio%a!!", as a))$o)$iate, the" a$e e8)e ted to i%(esti&ate a%d im)!eme%t )$a ti e a!te$atio%s to a(oid i%Du$" i% the #utu$e- The )h"si ia%s themse!(es o%du t the a tua! dis !osu$e o%(e$satio%s- The )h"si ia%s do %ot ha%d!e om)e%satio% matte$s but i%#o$m the )atie%t o# the COPIC !aims )$o essTCOPIC 'i!! $eimbu$se )atie%ts #o$ out6o#6)o 4et medi a! e8)e%ses $e!ated to the ad(e$se e(e%t, u) to the (a!ue o# Z21,333 E)!us u) to Z1,333 #o$ $e o&%i5ed !oss o# timeF- The )atie%t must submit

104

Fo$ $e#e$e% es o% COPIC, see: Thomas Ga!!a&he$ a%d Ri he$t Sui%%, B.hat to Do 'ith the U%a%ti i)ated

Out ome: Does A)o!o&i5i%& Ma4e a Di##e$e% eI Ho' does Ea$!" Reso!utio% Im)a t Sett!eme%t Out omesIC Pa)e$ P$ese%ted at Medical Liability and (ealthcare Law Seminar, Ma$ h ;, 233<- A essed o%!i%e 01 Ma" 2303 at htt):GG'''-'(mi - omGdo sGu%a%ti i)atedMout ome-)d#7 Thomas Ga!!a&he$, Da(id Studde$t, a%d .e%d" Le(i%so%, BDis !osi%& Ha$m#u! Medi a! E$$o$s to Patie%ts,C .ew "ngland $ournal of Medicine ;1<, %o- 2< E233@F:2@0;62@0?7 Mi he!!e M- Me!!o a%d Thomas H- Ga!!a&he$, BMa!)$a ti e Re#o$m6O))o$tu%ities #o$ Leade$shi) #o$ Hea!th Ca$e I%stitutio%s a%d Liabi!it" I%su$e$s,C

.ew "ngland $ournal of Medicine ;<2, %o- 01 E2303F:0;1;60;1<Ca$o!e A%%e Ta$$a%t, BCo)i 9s ;Rs P$o&$am: Re o&%i5e, Res)o%d to, a%d Reso!(e Patie%t I%Du$",C )o'e$)oi%t )$ese%tatio% at C PS C nnual Convening, A)$i! ;3, 2303- Po'e$)oi%t a essed o%!i%e 0= Ma" 2303 at htt):GG'''- a)sa -o$&Gdo ume%tsGTa$$a%t-CA-)d#- See s!ide 02-

105 106

Ga!!a&he$, Studde$t, a%d Le(i%so%, BDis !osi%& Ha$m#u! Medi a! E$$o$s to Patie%ts,C 2@0<-

107 Ca$o! +- Liebma% a%d Ch$is Ste$% H"ma%, Medical "rror %isclosure- Mediation S!ills- and Malpractice Litigation) %emonstration Pro6ect in Pennsylvania E2331F, htt):GG'''-)e't$usts-o$&Gou$M'o$4M$e)o$tMdetai!-as)8I idW2=;?A Ea essed 0? Ma" 2303F: <36<0=<

$e ei)ts to a% admi%ist$ato$ to )$o ess these )a"me%ts- 03A Pa$ti i)atio% i% the ;Rs )$o&$am does %ot )$e !ude )atie%tsG#ami!ies #$om #i!i%& #utu$e !iti&atio% i# the" so desi$e-

P$a titio%e$ )a$ti i)atio% i% the )$o&$am is i% e%ti(i5ed b" the #a t that u%de$ Co!o$ado !a', )a"me%ts made to )atie%tsG#ami!ies th$ou&h the COPIC ;Rs )$o&$am a$e %ot $e)o$tab!e to eithe$ the Natio%a! P$a titio%e$ Data +a%4 o$ the Co!o$ado +oa$d o# Medi a! E8ami%e$s- /usti#i atio% #o$ the e8 !usio% $ests o% the &$ou%ds that the )$o&$am is %ot a $es)o%se to a dema%d #$om the )atie%t a%d the )$o&$am does %ot as4 )atie%ts #o$ a 'ai(e$ o$ $e!ease03?

The$e is some disa&$eeme%t about the im)a t o# %ot

)ub!i !" $e)o$ti%& i% ide%ts, #o$ 'hi!e it ma" he!) )$ote t $e)utatio%s it ou!d a!so $edu e i%stitutio%a! !ea$%i%& #$om e$$o$s a%d #ai! to oust bad do to$s )$o(idi%& u%a e)tab!e !e(e!s o# a$e- To some'hat

miti&ate this o% e$%, ases $e&iste$ed a&ai%st a )h"si ia% a$e #!a&&ed i%te$%a!!" b" COPIC a%d ste)s a$e ta4e% to add$ess the issue i# COPIC deems it %e essa$"-

COPIC ;Rs9 )$o&$am &oa!s mat h those o# ma%" hos)ita!6based dis !osu$e )$o&$ams: mai%tai% the Ph"si ia%GPatie%t $e!atio%shi)7 e% ou$a&e o)e%Gho%est ommu%i atio% i% !udi%& dis !osu$e o# u%a%ti i)ated e(e%t7 e% ou$a&e e8)$essio%s o# o% e$% i% !udi%& a% a)o!o&" 'he% a))$o)$iate7 meet )atie%ts9 %eeds at $u ia! time, i% !udi%& %eed #o$ i%#o$matio%7 )$omotes )atie%t sa#et" a%d im)$o(ed *ua!it" o# a$e7 a%d $edu e !iti&atio% e8)e%ses003

Post6i% ide%t *uestio%%ai$es de!i(e$ed b" COPIC to )atie%ts a%d )$o(ide$s 'ho )a$ti i)ated i% thei$ ;Rs )$o&$am sho' that )atie%ts9 e(a!uatio%s o# the )$o ess a$e !a$&e!" #a(o$ab!e- Rates o# !iti&atio% #o!!o'i%& )a$ti i)atio% i% the ;Rs )$o&$am a$e !o', the )atie%t6)$o(ide$ $e!atio%shi) is a!most a!'a"s des $ibed as

108 109 110

Ga!!a&he$ a%d Sui%%, B.hat to do 'ith the U%a%ti i)ated Out ome,C 0=0Ga!!a&he$ a%d Sui%%, B.hat to do 'ith the U%a%ti i)ated Out ome,C 0=0Ta$$a%t, BCo)i 9s ;Rs P$o&$am,C 037 Ri he$t Sui%%, BCo)i 9s ;Rs P$o&$am: Re o&%i5e, Res)o%d to, a%d Reso!(e

Patie%t I%Du$",C )o'e$)oi%t )$ese%tatio%, htt):GG'''-so$$"'o$4s-%etG o)i -)htm! Ea essed 0= Ma" 2303F-

=@

i%ta t, a%d the #i%a% ia! data o% the )$o&$am sho's that it is #i%a% ia!!" ost e##e ti(e-

000

O%e %otab!e

a$e%a #o$ im)$o(eme%t o% e$%s )h"si ia%s9 ommu%i atio% s4i!!s du$i%& the dis !osu$e o%(e$satio%Suestio%%ai$e $esu!ts sho'ed that the B)atie%t9s )e$ e)tio% o# most )h"si ia%9s Qsi R ommu%i atio% QisR %ot #a(o$ab!e: Q)oi%ti%& toR )h"si ia%9s Qsi R #a!se )e$ e)tio%s o# thei$ o'% ommu%i atio% s4i!!s-C
002

This )oi%ts to the im)o$ta% e o# i% $easi%& )h"si ia%9s s4i!!s i% this a$e%a-

The si&%i#i a% e o# the COPIC ;Rs )$o&$am is that a% i%su$a% e om)a%", %ot a hea!th a$e de!i(e$" i%stitutio%, admi%iste$s the dis !osu$e )$o&$am- This is a 4e" ste) i% e8)a%di%& the sta4eho!de$s 'ho uti!i5e the a))$oa h, sho'i%& that sustai%ab!e busi%ess mode!s i% o$)o$ate dis !osu$e a$e )ossib!e, a%d mai%st$eami%& the ethi o# dis !osu$e-

5aiser Permanente) 'ntegrated Patient Response

I% ma%" dis !osu$e )$o&$ams, it is the $es)o%sib!e !i e%sed i%de)e%de%t )$a titio%e$ Et")i a!!" a )h"si ia%F i%(o!(ed 'ith the i% ide%t 'ho is e8)e ted to !ead the )atie%tG#ami!"- To su))o$t the a$e )$o(ide$ i% )$e)a$i%& #o$ a%d o%(e$satio% 'ith the

a$$"i%& out the dis !osu$e

o%(e$satio%, some #a i!ities ha(e estab!ished a Bdis !osu$e teamC i% !udi%& $e)$ese%tati(es #$om )atie%t sa#et", $is4 ma%a&eme%t, a%d !e&a! de)a$tme%ts- The Jaise$ Pe$ma%e%te s"stem sho's ho' dis !osu$e )$o&$ams a% be i%te&$ated 'ithi% a !a$&e$ s"stem #o$ )atie%t $es)o%se-

Jaise$ Pe$ma%e%te is the !a$&est %o%6)$o#it ma%a&ed hea!th )$o(ide$ i% the U%ited States- As a% i%te&$ated s"stem, the" ha(e )i!oted a%d ado)ted %ume$ous i%%o(atio% a))$oa hes to hea!th a$e de!i(e$"- The Hea!th Ca$e OmbudsGMediato$ s"stem EHCOMF is a% e8am)!e o# a )$o&$essi(e, om)$ehe%si(e $es)o%se to )atie%t6)$o(ide$ hea!th a$e o%#!i t, i% !udi%& ad(e$se out omes-

111 112

Sui%%, BCo)i 9s ;Rs P$o&$am,C s!ide 23Sui%%, BCo)i 9s ;Rs P$o&$am,C s!ide 23-

=A

I% the Jaise$ Pe$ma%e%te s"stem, the $es)o%sib!e a$e )$o(ide$s Eo#te% )h"si ia%sF a$e e8)e ted to !ead dis !osu$e a%d a)o!o&" o%(e$satio%s 'ith a )atie%tG#ami!"- Ho'e(e$, these o%(e$satio%s a$e imbedded 'ithi% a om)$ehe%si(e $es)o%se s"stem i% )!a e to add$ess u%a%ti i)ated out omes a%d )$o(ide %e essa$" su))o$t to )$o(ide$s a%d )atie%tsG#ami!ies th$ou&hout the )$o ess-

The #i$st om)o%e%t o# the s"stem is the #ou$6hou$ Commu%i ati%& U%a%ti i)ated Ad(e$se Out omes t$ai%i%& #o$ a$e )$o(ide$s-00; The t$ai%i%& o%te%t #o uses o% the im)o$ta% e o# &ood ommu%i atio% be#o$e, du$i%&, a%d a#te$ a% ad(e$se e(e%t- 00= The i%t$odu to$" t$ai%i%&s, as 'e!! as $e#$eshe$ t$ai%i%&s o% the same to)i , uti!i5e $o!e )!a"s a%d #eedba 4 sessio%s to $ei%#o$ e the )$i% i)!es- I% the ea$!" "ea$s, this t$ai%i%& 'as de!i(e$ed o%!" to )h"si ia%s but u$$e%t!" the aim is #o$ a!! membe$s o# the hea!th a$e team to $e ei(e this t$ai%i%&- Jaise$ Pe$ma%e%te $e&u!a$!" o##e$s additio%a! sta## t$ai%i%&s #o used o% ommu%i atio% i% the hea!th a$e e%(i$o%me%t that om)!eme%t this ou$se #o used s)e i#i a!!" o% ad(e$se out ome $es)o%ses-

Jaise$ Pe$ma%e%te a!so #o$med Situatio% Ma%a&eme%t Teams ESMTF to ta4e the !ead i% the ea$!" $es)o%se to a $e)o$t o# a% ad(e$se out ome001

This o$e team e%te$s the situatio% at a (e$" ea$!" sta&e Et")i a!!" 'ithi% @2

hou$s o# a $e)o$tF to assess the o%te8t, i%(esti&ate 'hat has ha))e%ed, a%d stabi!i5e the situatio%- P$o#essio%a!s #$om di##e$e%t dis i)!i%es om)$ise the team Esu h as $is4 ma%a&eme%t )h"si ia%s, medi a!6!e&a! )h"si ia%s, admi%ist$ato$s, a%d !i%i a! e8)e$ts, as $e*ui$ed b" the aseF so as to a!!o' it to add$ess a!! as)e ts o# the situatio%- S)e ia! t$ai%i%& is )$o(ided to the sta## 'ho se$(e o% the SMT, but it is %ot a #u!!6

113 The$e is %o' a 2-1 hou$ (e$sio% o# this t$ai%i%& as 'e!!- Autho$ te!e)ho%e i%te$(ie' 'ith Jath!ee% Ne!so%, Natio%a! Leade$, Patie%t U Fami!" Ce%te$ed Ca$e U Hea!thCa$e Ombudsma%GMediato$, Patie%t Sa#et" U Ris4 Ma%a&eme%t, Jaise$ Pe$ma%e%te, 0= Ma" 2303114 Jath!ee% C!a$4, BAd(o a " i% Hea!th Ca$e: A Sam)!e o# State a%d P$i(ate S"stems,C %ispute Resolution Maga&ine 0<, %o- ; ES)$i%& 2303F: 00115
C!a$4, BAd(o a " i% Hea!th Ca$e,C 007 a!so autho$ i%te$(ie' 'ith Jath!ee% Ne!so%-

=?

time )ositio%- Ge%e$a!!", )$o(ide$s a%d sta## $otate th$ou&h se$(i e o% the SMT as )a$t o# thei$ )$o#essio%a! $es)o%sibi!ities-

A#te$ the i%(esti&atio% is om)!ete a%d the situatio% has bee% stabi!i5ed, the Hea!th Ca$e OmbudsGMediato$ is a!!ed i%- The HCOM is a% i%te$%a! %eut$a! dedi ated to dis)ute $eso!utio%- The HCOM ma" be mobi!i5ed th$ou&h %ume$ous ha%%e!s to $es)o%d to a%" u%a%ti i)ated out ome, i% !udi%& times 'he% the )atie%t o$ #ami!" is sim)!" su$)$ised o$ disa))oi%ted 'ith the out ome o# thei$ t$eatme%t, 'hate(e$ the ause-00< The HCOM o)e$ates u%de$ the #ou$ )$i% i)!es o# im)a$tia!it", i%de)e%de% e, o%#ide%tia!it", a%d %eut$a!it"-00@ The" do ad(o ate #o$ the )atie%t, )$o(ide$, o$ o$&a%i5atio% but i%stead ad(o ate #o$ a #ai$ )$o ess to $eso!(e hea!th a$e issues, dis)utes, a%d o%#!i ts-00A The" a$e a(ai!ab!e at a%" time as a $esou$ e #o$ )atie%ts a%d #ami!ies a%d the" dedi ate 'hate(e$ time $e*ui$ed to the )a$ti i)a%ts a%d )$o ess- The" $emai% i% #$e*ue%t o%ta t 'ith )atie%tsG#ami!ies as the" #o!!o' the )atie%tG#ami!" th$ou&h to the e%d o# the u%a%ti i)ated out ome ase-

The aim is o# the HCOM is to $eso!(e issues as ea$!" as )ossib!e a%d at the !o'est )ossib!e !e(e!The" uti!i5e a $a%&e o# o%#!i t $eso!utio% s4i!!s a%d )$o esses i% thei$ 'o$4 'hi!e bui!di%& t$ust, ide%ti#"i%& i%te$ests, )$omoti%& mutua! u%de$sta%di%& o# %eeds a%d o% e$%s, a%d #a i!itati%&

00?

ommu%i atio%- The" assist both )$o(ide$s a%d )atie%tsG#ami!ies i% these a ti(ities- I% the o%te8t o# ad(e$se out omes, the" ou%se! )$o(ide$s o% e##e ti(e dis !osu$e o%(e$satio%s a%d ma" )!a" a di$e t $o!e i% #a i!itati%& them- The$e is #!e8ibi!it" i% the )$o edu$es a%d a ti(ities o# the HCOM, as a!! HCOMs a$e e8)e ted to e%te$ the )ositio% as s4i!!ed dis)ute $eso!utio% )$o#essio%a!s-

116 This a!so i% !udes disa))oi%tme%t due to Bu% o$$e ted Ou%$easo%ab!e9 e8)e tatio%s-C See T$a e" .a!4e$, BAd(o a " 'ith om)assio%: Do$oth" Ta$$a%t9s $o!e as hea!th a$e ombudsma%Gmediato$ )!a es he$ at the %e8us o# )atie%t6)$o(ide$ i%te$a tio%,C Managed (ealthcare "#ecutive E/u%e 0, 233<F, htt):GGma%a&edhea!th a$ee8e uti(e-mode$%medi i%e- omGmheGLisio%a$iesGAd(o a "6'ith6 om)assio%6Do$oth"6 Ta$$a%ts6$o!e6as6GA$ti !eSta%da$dGA$ti !eGdetai!G;2??21 Ea essed 01 Ma" 2303F117 118 119
C!a$4, BAd(o a " i% Hea!th Ca$e,C 00.a!4e$, BAd(o a " 'ith om)assio%-C C!a$4, BAd(o a " i% Hea!th Ca$e,C 00-

13

The HCOM $o!e is a #u!! time )ositio% dedi ated to $es)o%di%& to u%a%ti i)ated out omes- This a!!o's the HCOM to ta4e 'hate(e$ time is %e essa$" to assist )atie%tsG#ami!ies a%d )$o(ide$s 'ith as the" 'o$4 th$ou&h thei$ issues- A!! HCOMs a$e t$ai%ed as mediato$s a%d ombudsme%.hi!e some HCOMs ma" e%te$ the )ositio% th$ou&h a hea!th a$e ba 4&$ou%d, %o HCOMs ha(e !i%i a! duties- Jaise$ Pe$ma%e%te u$$e%t!" em)!o"s 2A HCOMs %atio%a!!"- 023

Im)$o(i%& )atie%t sa#et", e%ha% i%& )$o(ide$ a%d )atie%t satis#a tio%, a%d add$essi%& )atie%ts9 *ua!it" o# a$e o% e$%s Bi% a time!", em)atheti , a%d ho%est ma%%e$C a$e the &oa!s o# this )$o&$am- 020 .hi!e the$e ma" be a busi%ess ase to su))o$t this mode!, Jaise$ Pe$ma%e%te e8)!i it!" does %ot i%(o4e that as a Dusti#i atio%- The u!tu$e that Jaise$ Pe$ma%e%te attem)ts to bui!d a$ou%d its dis)ute $eso!utio% )$o&$ams is o%e based o% Bdoi%& the $i&ht thi%&-C 022

The HCOM does %ot ha%d!e Reso!utio% P$o&$am E!a$&e!"

om)e%satio% a##ai$s, as

ases a$e $e#e$$ed to the Ea$!"

om)$ised o# !e&a! sta##F #o$ #i%a% ia! $eimbu$seme%t o$

sett!eme%ts $e!ated to the u%a%ti i)ated out ome- 02; Patie%tsG#ami!ies a$e #$ee to b$i%& #u$the$ !e&a! a tio% $e&a$di%& the i% ide%t- HCOMs do %ot )a$ti i)ate i% this mo$e #o$ma! )$o ess02=

A!o%&side this, Jaise$ Pe$ma%e%te9s Em)!o"ee Assista% e P$o&$am EEAPF )$o(ides su))o$t #o$ !i%i ia%s a%d sta## #o!!o'i%& ad(e$se e(e%ts-021 .hi!e the EAP 'as o$i&i%a!!" i%te%ded to )$o(ide sta## su))o$t #o$

/oi%t Commissio% o% Hea!th Ca$e, 0arious Responses to Medical "rror- <@- A!so, autho$ te!e)ho%e i%te$(ie' 'ith Jath!ee% Ne!so%, Natio%a! Leade$, Patie%t U Fami!" Ce%te$ed Ca$e U Hea!thCa$e Ombudsma%GMediato$, Patie%t Sa#et" U Ris4 Ma%a&eme%t, Jaise$ Pe$ma%e%te, 0= Ma" 2303-

120 121 122 123 124 125

C!a$4, BAd(o a " i% Hea!th Ca$e,C 00.a!4e$, BAd(o a " 'ith om)assio%-C

C!a$4, BAd(o a " i% Hea!th Ca$e,C 02C!a$4, BAd(o a " i% Hea!th Ca$e,C 02Susa% Ca$$, BDis !osu$e a%d A)o!o&": .hat9s Missi%&I Ad(a% i%& P$o&$ams that Su))o$t C!i%i ia%s,C

Patient Safety and /uality (ealthcare EMa$ hGA)$i! 2303F, '''-)s*h- omGma$ ha)$i!6 2303G=126dis !osu$e6a%d6a)o!o&"6'hats6missi%&-htm! Ea essed 01 Ma" 2303F-

10

othe$ issues Esu h as 'o$4)!a e dis)utesF, the emotio%a! t$auma o# ad(e$se e(e%ts 'as $e o&%i5ed as a sou$ e o# 'o$4)!a e o%#!i t a%d )$o(ide$ (u!%e$abi!it"- P$o(idi%& su))o$t #o$ )$o(ide$s9 emotio%a! %eeds a% he!) )$o(ide$s $esto$e thei$ )$o#essio%a! o%#ide% e #o!!o'i%& a% ad(e$se e(e%t7 $e(ea! a%d add$ess )ast &$ie(a% es, a%&e$, a%d #$ust$atio%7 a%d !ead to bette$ )e$#o$ma% e a%d ommu%i atio%-02< .he% a% ad(e$se out ome o u$s, the EAP u%de$ the di$e tio% o# the Situatio% Ma%a&eme%t Team a ti(e!" $ea hes out to

)$o(ide$s i%(o!(ed 'ith the ase to head o## a%" )ote%tia! )$ob!ems a%d e%su$e that the" $e ei(e the su))o$t the" %eed- T")es o# su))o$t )$o(ided i% !ude a ta$&eted assista% e )$o&$am #o$ )h"si ia%s7 a %u$si%& )ee$6 su))o$t )$o&$am o##e$i%& &uida% e, o%su!tatio% a%d di$e tio%7 deb$ie#i%&7 o%e6o%6o%e ou%se!i%&7 $e#e$$a!7 a%d oo$di%atio% 'ith the i%stitutio%9s ha)!ai% " a%d so ia! se$(i es- 02@

ADR a))$oa hes to Ad(e$se Out omes a%d Medi a! Ma!)$a ti e Liti&atio%

Co%#!i t ma%a&eme%t $es)o%ses to ad(e$se out omes a$e !a$&e!" disti%&uished b" the )hase o# o%#!i t at 'hi h the $es)o%se is ta$&eted: )$e(e%tati(e7 ea$!" i%te$(e%tio% E)$e6!a'suitF7 a%d !ate i%te$(e%tio% E$es)o%se to !iti&atio%F-

Categor( One: 0re1entati1e Inter1entions

Provider "arly 'ntervention Model

Thou&h )$o(ide$ ea$!" i%te$(e%tio% t")i a!!" does %ot o%stitute a sta%d6a!o%e s"stem, it is a &oa! a%d a om)o%e%t o# ma%" s"stems-02A This mode! attem)ts to )$e)a$e )$o(ide$s to $e o&%i5e a%d add$ess u%#o!di%& )$ob!ems 'ith thei$ )atie%ts i% $ea! time, so as to $edi$e tG o$$e t a% e% ou%te$ that is t$e%di%&

Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t, %isclosure of Unanticipated "vents) The .e#t Step in 4etter Communication EChi a&o: Ame$i a% Hos)ita! Asso iatio%, Ma" 233;F: <6@htt):GG'''-ash$m-o$&Gash$mGedu atio%Gde(e!o)me%tGmo%o&$a)hsG Ea essed 01 Ma" 2303F-

126 127 128

Ca$$, BDis !osu$e a%d A)o!o&"-C Ca$$, BDis !osu$e a%d A)o!o&"-C

12

to'a$ds a %e&ati(e Eu%satis#a to$"F out ome- This a))$oa h $e!ies o% the )$a titio%e$, %ot a thi$d )a$t", #o$ i%te$(e%tio%- I% om)a$iso% to a!! othe$ $es)o%ses, this i%te$(e%tio% o u$s at the ea$!iest sta&e Eas )ote%tia! ad(e$se out ome is u%#o!di%&F- Su h i%te$(e%tio% is %ot )ossib!e i% a!! t")es o# ad(e$se out omes, as %ot a!!

ad(e$se out ome d"%ami s u%#o!d at a )a e that a!!o's #o$ o$$e tio% o$ ea$!" $e o&%itio%-

Desi&% #eatu$es: thi$d )a$t" $o!e is to )$o(ide t$ai%i%& a%d s4i!!6bui!di%& su))o$t-

Categor( T3o: Earl( Inter1entions 4pre5litigation6

'nternal .eutral (ealth Care *mbuds8Mediator =(C*M> Model

The I%te$%a! Neut$a! Hea!th Ca$e OmbudsGMediato$ mode! is dis)!a"ed )$omi%e%t!" i% the Jaise$
Pe$ma%e%te a%d the +ethesda Na(a! Medi a! Ce%te$ s"stems-02? The i%te$%a! ombudsGmediato$ dea!s 'ith

the %eeds o# both )$o(ide$s a%d )atie%ts- O#te% the" ou%se! )$o(ide$s o% ho' to ha(e a dis !osu$e o%(e$satio% a%d ma" )a$ti i)ate di$e t!" i% the dis !osu$e o%(e$satio%, a!thou&h i% ma%" s"stems the
hea!th a$e )$o(ide$ is e8)e ted to !ead the o%(e$satio%- I% additio%, the" assist 'ith $ea!it" he 4i%& #o$ )atie%ts7 he!) )atie%t %a(i&ate the s"stem7 a%d #a i!itate o%(e$satio%s a%d i%#o$matio% o!!e tio%Ge8 ha%&e-

OmbudsGmediato$s a$e e8)e ted to ha(e om)!eted ou$ses i% Mediatio% a%d Ombuds t$ai%i%&,
su))!eme%ted b" e8te%si(e o%#!i t ma%a&eme%t e8)e$ie% e- The )$io$ 'o$4 ba 4&$ou%d is (a$ied, 'ith

some e%te$i%& the )ositio% th$ou&h !i%i a! $outes 'hi!e othe$s ome th$ou&h ou%se!i%& o$ dis)ute
$eso!utio% ba 4&$ou%ds- This is t")i a!!" a #u!!6time )ositio%7 ombudsGmediato$s 'ith medi a! ba 4&$ou%ds

02?

The Medi a! Ombudsma%GMediato$s P$o&$am de(e!o)ed b" Ca$o! Hou4 o# Ca$o! Hou4 I%te$%atio%a! is a%othe$ e8am)!e o# this mode!- Hou4 'as i%st$ume%ta! i% desi&%i%& a%d s)$eadi%& this mode!- See htt):GG'''- hi6$eso!utio%s- omG #o$ mo$e detai!s- Fo$ $e#e$e% e to the +ethesda Na(a! Medi a! Ce%te$ e8)e$ie% e, see Ga$" +a! e$5a4 a%d Jath$"% Leo%ha$dt, BA!te$%ati(e Dis)ute Reso!utio% i% Hea!th a$e: A P$es $i)tio% #o$ I% $easi%& Dis !osu$e a%d Im)$o(i%& Patie%t Sa#et",C Patient Safety and /uality (ealthcare, /u!"GAu&ust 233A-

1;

t")i a!!" )e$#o$m %o !i%i a! duties- I%(o!(eme%t 'ith )atie%t a%d )$o(ide$ o% these ases ma" e8te%d to a "ea$ o$ be"o%d-

Desi&% #eatu$es: I%te$%a!, %eut$a!7 i%te$est6based, #a i!itati(e mediatio% a))$oa h7 $eates o))o$tu%ities #o$ a!! sides to be hea$d7 i% $eased #o us o% $e!atio%shi)s a%d *ua!it" o# a$eGe8)e$ie% e-

Liaison Physician Model

La$ious #o$ms o# a Liaiso% Ph"si ia% mode! a$e #ou%d i% )h"si ia% )$a ti e &$ou)s a%d hos)ita! #a i!ities- The$e a$e %ume$ous d"%ami s to 'hi h Liaiso% Ph"si ia%s ma" be assi&%ed: $e!atio%s 'ith s)e ia!ists7 $e!atio%s 'ith %u$si%& sta##, )atie%t bi!!i%& om)!ai%ts, a%d )atie%t6)$o(ide$ dis)utes a$e some o# the ommo% o%es-

This mode! t")i a!!" uti!i5es a desi&%ated )$a ti i%& !i%i ia% 'ith t$ai%i%& a%d s4i!!s i% o%#!i t ma%a&eme%t as a thi$d6)a$t" $es)o%de$ to a )atie%t om)!ai%t- The Liaiso% Ph"si ia% does %ot mediate bet'ee% )atie%t a%d )$o(ide$ but $athe$ e%te$s i%to a %e&otiatio% 'ith the )atie%t as a !i%i ia% $e)$ese%tati(e o# the )$a ti e &$ou) o$ i%stitutio%- The &oa! o# the i%te$(e%tio% is to #u!!" $eso!(e the )atie%t9s om)!ai%t i% a #ai$ a%d e##i ie%t ma%%e$ that !ea(es the )atie%t satis#ied- To a hie(e this, Liaiso% Ph"si ia%s use the o%#!i t $eso!utio% s4i!!s a%d te h%i*ues o# o%#!i t a%a!"sis, ide%ti#i atio% o# i%te$ests, a ti(e !iste%i%&, a%d Doi%t )$ob!em so!(i%&-

U%!i4e the Hea!th Ca$e OmbudsGMediato$ mode!s, the Liaiso% Ph"si ia% is %ot %eut$a!- Some Liaiso% Ph"si ia%s a$e i%(o!(ed 'ith #i%a% ia! as)e ts o# a $eso!utio%, a%d ma" be em)o'e$ed to ada)t )atie%t ha$&es o% thei$ bi!! o$ di$e t!" o##e$ om)e%satio%, a ti(ities i% 'hi h i%te$%a! %eut$a!s do %ot di$e t!" )a$ti i)ate- Fu$the$mo$e, u%!i4e most i%te$%a! %eut$a!s, some !iaiso% )h"si ia%s )e$#o$m e(o!(i%& $o!es as

1=

the" ma" )a$ti i)ate i% a ase th$ou&hout a!! o# its sta&es, #$om the i%itia! i%(esti&atio% th$ou&h mediatio% to a$bit$atio%, !iti&atio%, a%d om)e%satio%-

The t$ai%i%& #o$ the Liaiso% Ph"si ia% $o!e is simi!a$ to that #o$ a% HCOM, a!thou&h it ma" %ot be as i%6de)th- O#te% the Liaiso% Ph"si ia% $o!e is %ot a #u!!6time )ositio%7 i% some o%te8ts, it ma" be a $otati%&, %o%6$eimbu$sed dut" #o$ !i%i ia%s that the" a$e e8)e ted to #i!! as )a$t o# thei$ )$o#essio%a! ob!i&atio%s to the hos)ita! o$ )$a ti e &$ou)-

Liaiso% Ph"si ia%s a$e !i4e!" a%didates #o$ ad(a% ed o%#!i t $eso!utio% t$ai%i%&s-

Desi&% #eatu$es: I%te$%a!, %o%6%eut$a!7 i%te$est6based, #a i!itati(e mediatio% a))$oa h7 $eates o))o$tu%ities #o$ a!! sides to be hea$d7 i% $eased #o us o% $e!atio%shi)s a%d *ua!it" o# a$eGe8)e$ie% e-

%isclosure Support Team Model

This mode!, i% use b" the Ad(o ate Luthe$a% Ge%e$a! Hos)ita! i% I!!i%ois, se$(es as a% ad(iso$" $esou$ e to )$o(ide$s i%(o!(ed 'ith u%a%ti i)ated out omes0;3

The Dis !osu$e Su))o$t Team, o#te%

i%itia!!" o%ta ted b" a )$o(ide$ 'ho has ide%ti#ied a% u%a%ti i)ated out ome, )$o(ides ad(i e o% ho' to o%du t dis !osu$e o%(e$satio%s a%d su))o$t to the )$o(ide$ o% se!#6 a$e- Membe$s o# the Dis !osu$e Su))o$t Team ma" o$ ma" %ot )a$ti i)ate i% the dis !osu$e o%(e$satio%-

This mode! is most a%a!o&ous to a o%#!i t oa hi%& d"%ami , $athe$ tha% a mediatio% d"%ami - The Dis !osu$e Su))o$t Team is %ot %eut$a!-

0;3

/u!ie Mo$ath a%d Te$$" Ha$t, BPa$t%e$i%& 'ith #ami!ies: dis !osu$e a%d t$ust,C )a)e$ )$ese%ted at

.ational Patient Safety 7oundation8 $C (* Patient Safety 'nitiative 2999) Spotlighting Strategies- Sharing Solutions EO tobe$ <, 23337 Chi a&o, ILFhtt):GG'''-%)s#-o$&Gdo'%!oadGMo$ath-)d# Ea essed 0= Ma" 2303F-

11

The mode! is a!so used b" )h"si ia% ma!)$a ti e i%su$a% e om)a%ies su h as The %octors Company- I% thei$ ase, the Dis !osu$e Su))o$t Team is the Patie%t Sa#et" G Ris4 Ma%a&eme%t de)a$tme%t- Ad(o a " #o$ dis !osu$e meeti%&s b" i%su$a% e om)a%ies is a% im)o$ta%t de(e!o)me%t as it sho's ho' dis !osu$e has mo(ed be"o%d hos)ita!s a%d a ademi a$e e%te$s to'a$ds the mai%st$eam u!tu$e o# hea!th a$e-0;0

Desi&% #eatu$es: I%te$%a!, %ot %eut$a!, %ot )a$t" to o%(e$satio%7 #o used o% ommu%i atio%, e% ou$a&es o))o$tu%ities #o$ !iste%i%& a%d sha$i%& e8)e$ie% es7

CPinch hitterD Model

I% this mode!, a $a)id $es)o%se team ma" be b$ou&ht i% to $esea$ h a%d o%du t the dis !osu$e o%(e$satio%, 'ith the )$o(ide$ de!ibe$ate!" situated o% the )e$i)he$" o# the )$o ess- The $a)id $es)o%se team does %ot )!a" the $o!e o# a %eut$a! mediato$ but i%stead is a di$e t )a$t" to the dis !osu$e o%(e$satio%Suestio%s a$ise $e&a$di%& the im)a t o# this a))$oa h o% the d"%ami o# the dis !osu$e o%(e$satio%, )atie%t )e$ e)tio%s o# the i%te$a tio%, a%d the be%e#its o# usi%& e8)e$ie% ed dis !osu$e teams (e$sus the )ote%tia! dama&e to the !i%i ia%6)atie%t $e!atio%shi) due to %o%6)a$ti i)atio% o$ %o%6 ommu%i atio% b" the !i%i ia% i% the o%(e$satio%- 0;2 This a))$oa h ma" de)$i(e the )atie%t o# the o))o$tu%it" to hea$ di$e t!" #$om the )$o(ide$ $es)o%sib!e #o$ the ad(e$se out ome e(e%t, )ote%tia!!" dimi%ishi%& the )ositi(e im)a t o# the dis !osu$e o%(e$satio% a!to&ethe$-0;;

0;0

See The Do to$s Com)a%"9s Dis !osu$e P$o&$am 'ebsite, htt):GG'''-thedo to$s- omGJ%o'!ed&eCe%te$GPatie%tSa#et"GDis !osu$eResou$ esGCONMIDM3303;?Ea essed 0= Ma" 2303F0;2 Ga!!a&he$, Studde$t, a%d Le(i%so%, BDis !osi%& Ha$m#u! Medi a! E$$o$s to Patie%ts,C 2@0;0;; Liebma% a%d H"ma%, BMediati%& Medi a! Ma!)$a ti e La'suits,C A7 COPIC, Copic Tip) Lessons Learned from the 1Rs program, 0 Ma" 2303, htt):GG'''- a!! o)i - omG$esou$ esG ustomGPDFG o)i 6 ti)sGLesso%sK23Lea$%edK23#$omK23theK23;RsK23P$o&$am-)d# Ea essed 01 Ma" 2303F-

1<

Desi&% #eatu$es: I%te$%a!, %ot %eut$a!7 )a$t" to o%(e$satio%7 usua!!" #o used o% #a i!itati(e, i%te$est6based a))$oa h to $eso!(i%& )$ob!ems7 #o us o% ommu%i atio%-

University of 'llinois Program) 7aster Response

A mo$e $e e%t )$o&$am E!au% hed i% 233<F that is )$o(i%& su

ess#u! i% o%e o# the mo$e

ha!!e%&i%& medi a! ma!)$a ti e !iti&atio% e%(i$o%me%ts is the dis !osu$e )$o&$am at the U%i(e$sit" o# I!!i%ois Medi a! Ce%te$ i% Chi a&o- .hi!e this )$o&$am uti!i5es most )$oto o!s o# the So$$" .o$4sY Mode!, u%i*ue #eatu$es o# this )$o&$am i% !ude: 0;=

1 S)eed o# )$o essi%&: thei$ &oa! is to i%(esti&ate, a)o!o&i5e, sett!e o$ mediate, a%d !ea$%
#$om mista4es 'ithi% <3 da"s o# a% ad(e$se e(e%t- The" t$" to om)!ete i%(esti&atio%s 'ithi% @2 hou$s o# a $e)o$t-

2 Ra)id i%(esti&atio% team a%d a e$$o$ dis !osu$e team t$ai%ed i% ommu%i ati%& 'ith
)atie%ts a%d #ami!ies a#te$ a% ad(e$se e(e%t

3 Patie%t !iaiso% assi&%ed to 'o$4 'ith the )atie%tG#ami!" o%sta%t!" th$ou&hout the )$o ess 4 Sta## su))o$t se$(i es #o used o% add$essi%& the emotio%a! im)a t o# ad(e$se
e(e%ts o% the )$o(ide$s i%(o!(ed

5 A%o%"mous hot!i%e to $e)o$t ad(e$se e(e%ts to the $is4 team Esee% as es)e ia!!"
he!)#u! #o$ e%ab!i%& !o'e$6!e(e! em)!o"ees to #ee! om#o$tab!e $e)o$ti%& i% ide%tsF

6 I%stitutio% o# a $obust, %o%6)u%iti(e $e(ie' s"stem to s"stemati a!!" !ea$% #$om mista4es 7
Abi!it" to immediate!" sto) a!! bi!!i%& to a )atie%t i% the e(e%t o# a% ad(e$se e(e%t !aim Eas e$$a%t bi!!s o$ o!!e tio% %oti es 'e$e see% as ha(i%& the abi!it" to dis$u)t the 'ho!e )$o essF

0;=

So$$" .o$4sY 'ebsite, BNe' Dis !osu$e P$o&$am at U%i(e$sit" o# I!!i%ois Medi a! Ce%te$ i% Chi a&o,C '''-so$$"'o$4s-%et Ea essed 01 Ma" 2303F7 see a!so /oi%t Commissio% o% Hea!th Ca$e EState o# Li$&i%iaF, 0arious Responses to Medical "rror) Report %ocument .o+ :9; ERi hmo%d, LA: Commo%'ea!th o# Li$&i%ia, 233?F: <0-

1@

A#te$ thei$ #i$st "ea$ o# im)!eme%tatio% E233<G3@F, the" had o%e !aim i% =3 dis !osu$es, 'hi h 'as ited as a% e8 e)tio%a! $ate #o$ the Coo4 Cou%t" !iti&atio% e%(i$o%me%t- I% additio% to )h"si ia% a%do$ a%d a)o!o&", &ood ustome$ se$(i e 'ith e8 e!!e%t ommu%i atio% s4i!!s a%d e##e ti(e )$ob!em so!(i%& 'e$e see% as 4e" e!eme%ts to this su ess-

Desi&% #eatu$es: I%te$%a!, %ot6%eut$a!7 di$e t )a$ti i)atio% i% o%(e$satio%s7 (a$ious a to$s oa hi%&G#a i!itati%& at di##e$e%t )oi%ts7 i%te$est6based, #a i!itati(e a))$oa h to )$ob!em so!(i%&-

"#ternal .eutral) Mediating %isclosure prior to litigation

The COPIC ;Rs )$o&$am uti!i5es e8te$%a! %eut$a!s to mediate di##i u!t dis !osu$e o%(e$satio%s- I% the )ub!ished !ite$atu$e, it 'as %ot !ea$ 'ho ma4es the de isio% i% the COPIC s"stem #o$ the )h"si ia%s to ho!d the dis !osu$e o%(e$satio% o% thei$ o'% o$ as )a$t o# mediatio%-

Categor( T&ree: "esponses to Litigation

A (a$iet" o# ADR )$o essesTi% !udi%& a$bit$atio%, mediatio%, ea$!" %eut$a! e(a!uatio%, a%d o% i!iatio%T a$e #$e*ue%t!" uti!i5ed )$o esses to he!) sett!e medi a! ma!)$a ti e !a'suits outside o# the ou$t$oom- Le&a! ou%se! t")i a!!" )!a"s a e%t$a! $o!e i% these ADR $es)o%ses to !a'suits that ha(e a!$ead" bee% #i!ed-

The im)a t o# medi a! ma!)$a ti e

!aims o% )h"si ia% $e)utatio% is a% im)o$ta%t #a to$ i% this

ate&o$" o#

$es)o%ses- I% most i$ umsta% es, o% e a )!ai%ti##9s atto$%e" )$ese%ts a '$itte% dema%d #o$ om)e%satio% to a )h"si ia% de#e%da%t, subse*ue%t sett!eme%ts $esu!ti%& i% )a"outs o% beha!# o# )h"si ia%s must be $e)o$ted to the Natio%a! P$a titio%e$ Data +a%4 ENPD+F a%d, i% some states, to the +oa$d o# Medi a! E8ami%e$s

1A

E+MEF-0;1 This a))!ies e*ua!!" to sett!eme%ts %e&otiated th$ou&h mediatio%- As bei%& )ub!i !" $e)o$ted to the NPD+ o$ +ME a% ha(e !o%&6te$m im)a ts o% a )h"si ia%9s $e)utatio% a%d )$a ti e, this a% si&%i#i a%t!" dam)e% )h"si ia%s9 e%thusiasm #o$ ma4i%& !ate6sta&e sett!eme%ts th$ou&h a%" ha%%e!-0;<

ADR i%te$(e%tio%s that a% i%te$$u)t the !iti&atio% )$o ess be#o$e $e)o$ti%& to the NPD+ is $e*ui$ed a$e see% b" ma%" )h"si ia%s to o##e$ si&%i#i a%t be%e#its- 0;@

Pew %isclosure Mediation Model) 7acilitative mediation by an e#ternal neutral

I% this a))$oa h to medi a! ma!)$a ti e !iti&atio% a$isi%& #$om a% ad(e$se e(e%t, a% e8te$%a! %eut$a! o$&a%i5es a%d o%du ts a #a i!itati(e mediatio% that i% !udes a!! )a$ties a%d thei$ !e&a! ou%se!- This )$o ess aims to im)$o(e ommu%i atio% bet'ee% )atie%t a%d )h"si ia%7 !ea$% #$om those e(e%ts7 a%d a$$i(e at #ai$ a%d ost6e##e ti(e sett!eme%t o# !aims- 0;A

Thei$ mode! $e omme%ds:

1 )h"si ia%s a%d othe$ hea!th a$e )$o#essio%a!s !ea$% ommu%i atio% s4i!!s #o$
dis !osu$e o%(e$satio%s7

2 )$o ess e8)e$ts he!) )!a%, o%du t, a%d deb$ie# dis !osu$e o%(e$satio%s7 3
hos)ita!s a!!o' )h"si ia%s a%d hos)ita! sta## the time %e essa$" #o$ dis !osu$e o%(e$satio%s7

4 a!! i%(o!(ed )a$ties, i% !udi%& )h"si ia%s a%d hos)ita! !eade$s, o##e$ a% a)o!o&"7 5 deb$ie#i%& a%d su))o$t o# hea!th a$e )$o#essio%a!s a#te$ the e$$o$ o$ ad(e$se e(e%t7 6 use o# mediatio% to sett!e )ote%tia! !aims-

135 Ed'a$d Daue$, BPosts $i)t o% Hea!th Ca$e Dis)ute Reso!utio%: Co%#!i t Ma%a&eme%t a%d the Ro!e o# Cu!tu$e,C Georgia State University Law Review 20, %o- = ESumme$ 2331F, 03;?136 Ch$isto)he$ Guada&%i%o, BMa!)$a ti e Mediatio% Poised to E8)a%d,C Physician3s .ews %igest EA)$i! 233=F, htt):GG'''-)h"si ia%s%e's- omG o(e$G=3=-htm! Ea essed 0? Ma" 2303FLiebma% a%d H"ma%, Medical "rror %isclosure7 see a!so Ga$" +a! e$5a4 a%d Jath$"% Leo%ha$dt, BA!te$%ati(e Dis)ute Reso!utio% i% Hea!th a$e: A P$es $i)tio% #o$ I% $easi%& Dis !osu$e a%d Im)$o(i%& Patie%t Sa#et",C Patient Safety and /uality (ealthcare E/u!" G Au&ust 233AF-

137 138

Guada&%i%o, BMa!)$a ti e Mediatio% Poised to E8)a%d-C

1?

This mode! em)!o"s ma%" o# the same #eatu$es, )$o esses, a%d &oa!s as the i%te$%a! %eut$a! Hea!th Ca$e ombudsGmediato$ s"stem, a!thou&h these %eut$a!s a$e &e%e$a!!" a!!ed o% to e%&a&e 'ith the dis)ute at a mu h !ate$ sta&e- It #o uses o% ide%ti#"i%& i%te$ests7 ad(ises di$e t )a$ti i)atio% b" the $es)o%sib!e hea!th a$e )$o(ide$ i%(o!(ed 'ith the !iti&atio%7 )$o(ides o))o$tu%ities #o$ a!! )a$ti i)a%ts E$athe$ tha% thei$ !e&a! ou%se!F to te!! thei$ sto$" a%d be hea$d7 e% ou$a&es #u!!6dis !osu$e a%d a)o!o&"7 e% ou$a&es a!! )a$ties to ta!4 'ith o%e a%othe$ th$ou&hout a!! sessio%s7 su))o$ts the e8)$essio% emotio%7 )$o(ides $ea!it"6 he 4i%& $athe$ tha% e(a!uatio%7 see4s to he!) ide%ti#" i%#o$matio% use#u! #o$ ha%&i%& hos)ita! )o!i ies a%d s"stems E#o$ i%stitutio%a! !ea$%i%& a%d im)$o(ed )atie%t sa#et"F7 a%d he!)s )a$ties e8)!o$e a!te$%ati(e sett!eme%t o)tio%s- 0;?

The Pe' Demo%st$atio% a%d Mediatio% P$oDe t 'as a t'o6"ea$ demo%st$atio% )$o&$am )i!oted i% #ou$ hos)ita!s i% Pe%%s"!(a%ia- .hi!e o%!" a sma!! %umbe$ o# ases 'e$e mediated u%de$ this s"stem, it is a% e8am)!e o# ho' s"stems ma" use e8te$%a! %eut$a!s #o$ mediatio%s i%(o!(i%& dis !osu$e o%(e$satio%s at !ate$ sta&es, a#te$ the !iti&atio% )$o ess has bee% a ti(atedP$o&$ams ado)ti%& simi!a$ a))$oa hes o%ti%ue to be i%t$odu ed a%d assessed- 0=3

Desi&% #eatu$es: E8te$%a! %eut$a!7 !eads )$o ess o# i%te$est6based, #a i!itati(e mediatio%7 )a$ti i)atio% i% the )$o ess is (o!u%ta$" Eb" both )!ai%ti## a%d )h"si ia%F-

Rush Medical Center Model) "valuative Mediation

I% o%t$ast to a #a i!itati(e, i%te$est6based mediatio% a))$oa h ta4e% b" ma%" o# the mode!s me%tio%ed abo(e, e(a!uati(e, sett!eme%t6 o%#e$e% e mediatio% is a!so used i% medi a! ma!)$a ti e ases- This st"!e o#

Ch$is Ste$% H"ma% a%d Ca$o! Liebma%, BMediati%& Medi a! Ma!)$a ti e La'suits: The Need #o$ P!ai%ti## a%d Ph"si ia% Pa$ti i)atio%,C %ispute Resolution Maga&ine 0<, %o- ; ES)$i%& 2303F, A-

139 140

Liebma% a%d H"ma%, Medical "rror %isclosure- @A-

<3

mediatio% is !a$&e!" o%du ted bet'ee% the mediato$ a%d !e&a! ou%se! #o$ the )!ai%ti## a%d de#e%da%t- E(a!uati(e mediato$s t")i a!!" s)e%d $e!ati(e!" !itt!e time i% Doi%t sessio%, do %ot e% ou$a&e the )a$ti i)atio% o# the )!ai%ti## a%d de#e%da%t, a%d #o us !a$&e!" o% the e o%omi issues o# the ase-0=0 These mediatio%s $a$e!" dea! 'ith emotio%s o$ u%de$!"i%& i%te$ests a%d te%d to see4 so!utio%s based o% the )a$ties9 ad(e$sa$ia! mo%eta$" )ositio%s0=2

A )$omi%e%t e8am)!e o# this a))$oa h is a mode! #o$ o6mediati%& medi a! ma!)$a ti e !iti&atio% that eme$&ed #$om the Rush6P$esb"te$ia%6St- Lu4e9s Medi a! Ce%te$ i% Chi a&o i% the mid6 0??3s- The Rush mode! aims #o$ ea$!" sett!eme%t o# #i!ed medi a! ma!)$a ti e !a'suits )$io$ to the ou$t hea$i%& the ase i% ou$t- It !a$&e!" uti!i5es a% e(a!uati(e st"!e o# mediatio%, i% 'hi h e8te$%a! %eut$a! mediato$s assess the st$e%&ths a%d 'ea4%esses o# the )a$ties9 )ositio%s a%d su&&est a (a!ue $a%&e #o$ sett!eme%t, 'ith !itt!e time s)e%t i% dia!o&ue o$ Doi%t sessio%- 0=; This (o!u%ta$" )$o ess be&i%s 'ith a Doi%t meeti%& i%t$odu i%& the mediatio% a))$oa h to both the )!ai%ti## a%d the de#e%se, i% !udi%& thei$ !e&a! ou%se!- This meeti%& )$o(ides a% o(e$(ie' o# the te$ms a%d o%ditio%s o# the mediatio%, des $ibi%& o%#ide%tia!it", de#i%i%& #i%a!it", out!i%i%& au us )$o edu$es, a%d e8)!ai%i%& that both sides sha$e e*ua!!" the mediatio% e8)e%ses-

The )!ai%ti## a%d his o$ he$ atto$%e" the% se!e t a mediato$ #$om a !ist o# )$a ti i%& medi a! ma!)$a ti e t$ia! !a'"e$s t$ai%ed i% mediatio%-0== Ha(i%& the )!ai%ti## se!e t the mediato$ is desi&%ed as a% i%du eme%t #o$ the )!ai%ti## to )a$ti i)ate- A se o%d !a'"e$ is the% assi&%ed as a o6mediato$, i%te%tio%a!!" )ai$i%& a

141 142 143 144

H"ma% a%d Liebma%, BMediati%& Medi a! Ma!)$a ti e La'suits,C @H"ma% a%d Liebma%, BMediati%& Medi a! Ma!)$a ti e La'suits,C @H"ma% a%d Liebma%, Medical "rror %isclosure- @=Guada&%i%o, BMa!)$a ti e Mediatio% Poised to E8)a%d-C

<0

!a'"e$ 'ho 'ou!d t")i a!!" ha%d!e a )!ai%ti##9s medi a! ma!)$a ti e ase 'ith a !a'"e$ 'ho t$aditio%a!!" de#e%ds these ases-0=1

Ge%e$a!!" these mediatio%s o detai!s ha(i%& a!$ead" o

u$ at a #ai$!" !ate sta&e i% the !iti&atio% )$o ess 'ith most dis o(e$" o# ase

u$$ed- 0=< A t")i a! mediatio% be&i%s 'ith ea h side Eusua!!" the atto$%e"sF

ma4i%& a b$ie# o)e%i%& )$ese%tatio%7 the )a$ties a$e a!so o##e$ed the o))o$tu%it" to s)ea4, i# the" hooseThe mediato$s the% shutt!e bet'ee% se)a$ate au uses 'ith ea h side u%ti! the )a$ties a&$ee o% a sett!eme%t #i&u$e- The )a$ties the% $e o%(e%e i% a Doi%t sessio%, a##i$m the te$ms o# sett!eme%t, a%d e8 ha%&e omme%ts-0=@ The hos)ita! $e)$ese%tati(e ma" o##e$ a% a)o!o&" o# s"m)ath" du$i%& the mediatio%, thou&h this &e%e$a!!" 'i!! %ot i% !ude a% a 4%o'!ed&eme%t o# !iabi!it"- 0=A

Rush i%stituted this s"stem to !o'e$ !e&a! de#e%se osts a%d )$o(ide a mo$e $e!iab!e )$o edu$e #o$ sett!i%& medi a! ma!)$a ti e dis)utes-0=? I% !i%e 'ith this, Rush estab!ished de#i%itio%s o# su ess #o$ this )$o&$am:013

.ou!d the sett!eme%t (a!ue o# ases $eso!(ed th$ou&h mediatio% be i% $eased o$ $edu edI

2 .ou!d de#e%se osts be i% $eased o$ $edu edI 3

.ou!d i%itiati%& the )$o&$am ause )!ai%ti##sV atto$%e"s to sue Rush 'ith &$eate$ #$e*ue% "I

Data e(a!uati%& the ea$!" )e$#o$ma% e o# this mode! o# o6mediatio% i%di ates that the" 'e$e su ess#u! o% a!! th$ee $ite$ia- O(e$a!!, a))$o8imate!" o%e6thi$d o# medi a! ma!)$a ti e ases i%(o!(i%& Rush e%te$ (o!u%ta$" mediatio%- ?3K o# mediated ases a$e su ess#u!!" sett!ed, 'ith A3K o# the ases $eso!(ed 'ithi%

Guada&%i%o, BMa!)$a ti e Mediatio% Poised to E8)a%dC7 H"ma% a%d Liebma%, Medical "rror %isclosure- @=-

145 146 147 148 149

+a! e$5a4 a%d Leo%ha$dt, BA!te$%ati(e Dis)ute Reso!utio% i% Hea!th a$e-C H"ma% a%d Liebma%, Medical "rror %isclosure- @=H"ma% a%d Liebma%, Medical "rror %isclosure- @1H"ma% a%d Liebma%, Medical "rror %isclosure- @=-

150 /oh% Coo!e", BA dose o# ADR #o$ the hea!th EFeb$ua$"GA)$i! 2332F: 23-

a$e i%dust$",C %ispute Resolution $ournal 1@, %o- 0

<2

o%e "ea$ o# the #i!i%& o# the !a'suit- U)o% $ea hi%& mediatio%, the (ast maDo$it" o# sett!eme%ts a$e $ea hed 'ithi% th$ee to #ou$ hou$s o# mediatio%-010 F$om the hos)ita!9s )e$s)e ti(e, this b$ou&ht si&%i#i a%t #i%a% ia! be%e#its as 'e!!- Com)a$ed to simi!a$ %o%6mediated ases, the mediated ases a$e $eso!(ed mo$e *ui 4!" Ei% o%e6ha!# to t'o6thi$ds the time i% 'hi h simi!a$ %o%6mediated ases ame be#o$e a Du$" o$ 'e$e sett!edF, 'ith !o'e$ )a"6outs Ea =36<3K sa(i%&s i% )a"me%ts, thou&h )atie%ts $e)o$ted bei%& satis#ied 'ith the !o'e$ amou%ts be ause o# the #aste$ s)eed o# $eso!utio%F, a%d 'ith a 136@3K $edu tio% i% !e&a! de#e%se #ees- 012

Co% e$%s that the su ess o# a $e!ati(e!" *ui 4 a%d ost6e##e ti(e mediatio% )$o&$am mi&ht att$a t a% i% $ease i% the %umbe$ o# !a'suits ha(e so #a$ )$o(ed u%#ou%ded, as $esu!ts i%di ated a $edu tio% i% !a'suits #i!ed du$i%& the ea$!" "ea$s o# stud"- 01;

Rush o%ti%ues to use this mode!, iti%& its su ess i% meeti%& the i%te$ests, o% e$%s, a%d emotio%a! %eeds o# )atie%ts a%d )$o(ide$s7 $edu i%& the osts a%d time i%(o!(i%& 'ith t$aditio%a! $es)o%ses to !iti&atio%7 a hie(i%& 'i%6'i% so!utio%s th$ou&h a!te$%ati(e a))$oa hes to sett!eme%t7 a%d &ai%i%& su))o$t #$om both )!ai%ti## a%d de#e%se atto$%e"s- 01=

Ho'e(e$, this mode! has bee% $iti i5ed #o$ its o(e$a$ hi%& e(a!uati(e a))$oa h to mediatio%Liebma% a%d H"ma% a$&ue that the Rush mode! #ai!s to $ea!i5e the #u!! be%e#its o# mediatio%, !aimi%& it #o uses a!most e8 !usi(e!" $ea hi%& a mo%eta$" sett!eme%t011

The" !aim that the

e(a!uati(e a))$oa h misses o))o$tu%ities #o$ $e)ai$i%& $e!atio%shi)s, e8)!o$i%& %o%6mo%eta$" $emedies, a%d dis o(e$i%& i%#o$matio% that 'ou!d )$omote )atie%t sa#et"01<

+a! e$5a4 a%d Leo%ha$dt, BA!te$%ati(e Dis)ute Reso!utio% i% Hea!th a$e,C 237 Guada&%i%o, BMa!)$a ti e Mediatio% Poised to E8)a%dC7 Coo!e", BA dose o# ADR,C 23-

151 152 153 154 155 156

Coo!e", BA dose o# ADR,C 23-

Data a(ai!ab!e o(e$ed u%ti! 2332- Coo!e", BA dose o# ADR,C 23+a! e$5a4 a%d Leo%ha$dt, BA!te$%ati(e Dis)ute Reso!utio% i% Hea!th a$e,C 23Liebma% a%d H"ma%, Medical "rror %isclosure- @;Liebma% a%d H"ma%, Medical "rror %isclosure- @=-

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The D$e8e! U%i(e$sit" Co!!e&e o# Medi i%e estab!ished a mediatio% )$o&$am that ado)ts the basi #$ame'o$4 o# the Rush mode! but i%te&$ates #eatu$es o# dis !osu$e o%(e$satio%s a%d #a i!itati(e mediatio%01@

Li4e the Rush Mode!, it uti!i5es o6mediato$s se!e ted #$om a )oo! o# )$a ti i%& t$ia!

!a'"e$s to o%du t the mediatio%- U%!i4e the Rush mode!, the #o us o# the mediatio% is o% $e)ai$i%& the )atie%t6)h"si ia% $e!atio%shi)- +oth )atie%t a%d )h"si ia% atte%d a%d s)ea4-

Desi&% #eatu$es: E8te$%a! %eut$a!7 o6mediatio% b" )$a ti i%& t$ia! !a'"e$s7 e(a!uati(e mediatio% st"!e7 )atie%t G )$o(ide$ )a$ti i)atio% o#te% mi%ima!7 %o #u!! a)o!o&"-

C- Sha$ed De isio% Ma4i%&

Sha$ed de isio% ma4i%& ESDMF is a bu$&eo%i%& e8am)!e o# o%#!i t ma%a&eme%t i% hea!th a$e- 01A
Mo(eme%ts )$omoti%& )atie%t e%&a&eme%t #o$ )atie%t sa#et" a$e o%e as)e t o# sha$ed de isio% ma4i%&-01?
I% attem)ts to im)$o(e )atie%t sa#et" a%d *ua!it" o# a$e, hos)ita!s a$e i% $easi%&!" )$omoti%& a )a$t%e$s6i%6 a$e mode! bet'ee% )atie%ts, thei$ #ami!ies, a%d )$o(ide$s0<3

Pediat$i hos)ita!s ha(e bee% es)e ia!!" a ti(e i%

attem)ti%& to i%(o!(e )atie%ts a%d #ami!" i% a$e de isio%s a%d a$e de!i(e$" as a )$odu ti(e sou$ e o# di##e$i%& o)i%io% a%d )e$s)e ti(e0<0

The 4e" assum)tio% is that 'he% )atie%ts a%d #ami!ies a$e e% ou$a&ed to as4

*uestio%s a%d )a$ti i)ate i% a$e o# thei$ hi!d$e%, the" a$e mo$e !i4e!" to t$ust i% the a$e&i(e$s a%d the i%stitutio% as a 'ho!e0<2

This is simi!a$ to the #o us o% im)$o(ed ommu%i atio% bet'ee% )atie%ts a%d

De%ise Niemi$a, BEthi s Co%#!i ts i% Ru$a! Commu%ities: Sha$ed De isio% Ma4i%&,C i% (andboo! for Rural (ealthcare "thics- ed- .i!!iam A- Ne!so% EHa%o(e$, NH: T$ustees o# Da$tmouth Co!!e&e, 233?F: 0==60<;htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG#u!!6boo4-)d# Ea essed 0= Ma" 2303F-

157 158 159 160 161 162

Liebma% a%d H"ma%, Medical "rror %isclosure- @=-

See the .HO Patie%ts #o$ Patie%t Sa#et" Cam)ai&% #o$ e8am)!es- A(ai!ab!e o%!i%e at

htt):GG'''-'ho-i%tG)atie%tsa#et"G)atie%tsM#o$M)atie%tGe%G Ea

essed 01 Ma" 2303F-

A%d$ea S obie a%d D- Da(id Pe$saud, BPatie%t E%&a&eme%t i% Patie%t Sa#et": +a$$ie$s a%d Fa i!itato$s,C Patient Safety and /uality (ealthcare EMa$ hGA)$i! 2303F, htt):GG'''-)s*h- omGma$ ha)$i!62303G=1=6)atie%t6 e%&a&eme%t6i%6)atie%t6sa#et"6ba$$ie$s6a%d6#a i!itato$s-htm! Ea essed 2A Ma" 2303FMo$ath a%d Ha$t, BPa$t%e$i%& 'ith #ami!ies-C Mo$ath a%d Ha$t, BPa$t%e$i%& 'ith #ami!ies,C ;-

<=

)$o(ide$s dis ussed abo(e, 'ith i% $eased #o us o% the )atie%t 6 )$o(ide$ $e!atio%shi), i%#o$med o%se%t,

)atie%t )$e#e$e% es, a%d st$u tu$es #o$ sha$i%& i%#o$matio% a%d ma4i%& de isio%s- 0<;

Co% e$%s 'ith the ost o# hea!th a$e i% the US a$e $aisi%& e8)e tatio%s that both )atie%ts a%d )$o(ide$s be o%s ious o# the ost im)!i atio%s o# (a$ious )$o edu$es a%d t$eatme%t o)tio%s- This shi#t i% the #ie!d ma" i% $ease )$o(ide$ o%#!i ts 'ith both )atie%ts a%d )a"e$s o(e$ $esou$ e a!!o atio%, ost $eimbu$seme%t, a%d

de isio%6ma4i%& autho$it"- Add$essi%& these o%#!i ts 'i!! e%tai! %e' a))$oa hes to )$ob!em so!(i%&, im)a ti%& the t$aditio%a! hie$a$ hies o# 4%o'!ed&e a%d de isio%6ma4i%& )o'e$ i% )atie%t > )$o(ide$
$e!atio%shi)s- Hea!th a$e )$o(ide$s 'ho )$e(ious!" (ie'ed hea!th a$e de isio%s as too om)!e8 #o$ )atie%ts

to u%de$sta%d 'i!! i% $easi%&!" be e8)e ted to sha$e mo$e i%#o$matio% 'ith thei$ )atie%ts so that the )atie%ts a% ma4e mo$e i%#o$med, auto%omous de isio%s about t$eatme%t o)tio%s- Cost o% e$%s 'i!! i% $easi%&!" ma4e sha$ed de isio% ma4i%& a% im)o$ta%t %e' mode! #o$ ho' hea!th a$e is de!i(e$ed-

A!o%&side this, the$e is a se o%d (ei% o# sha$ed de isio% ma4i%& that e%te$s o% assisti%& )atie%ts 'ith de isio%a! o%#!i t- De isio%a! o%#!i t $e#e$s to )atie%ts st$u&&!i%& to se!e t #$om amo%& the a(ai!ab!e t$eatme%t o)tio%s- This (e$sio% o# sha$ed de isio% ma4i%& d$a's #$om the ba 4&$ou%d o# bioethi s dis)utes a%d di##i u!t e%d6o#6!i#e de isio%s Esee be!o'F- De isio%a! o%#!i t is #$e*ue%t!" asso iated 'ith
)$e#e$e% e6se%siti(e a$e but a% a!so a$ise 'he% )atie%ts a$e as4ed to )!a e (a!ue o% the )ote%tia! osts a%d

be%e#its o# ma%" t$eatme%t o)tio%s that had )$e(ious!" bee% de ided u%i!ate$a!!" b" )h"si ia%s- 0<= I% $easi%& o% e$%s 'ith ost, $esou$ e a!!o atio%, a%d )atie%t satis#a tio% $ates ma" shi#t mo$e o# the $es)o%sibi!it" #o$ de isio% ma4i%& o% to )atie%ts, ma4i%& de isio%a! o%#!i ts )ote%tia!!" e(e% mo$e

ommo% i% the #utu$e0<;

Ja$e% Se)hu ha, F!o"d Fo'!e$ /$-, a%d A!be$t Mu!!e" /$-, BPo!i " Su))o$t #o$ Patie%t6Ce%te$ed Ca$e: The Need #o$ Measu$ab!e Im)$o(eme%ts i% De isio% Sua!it",C (ealth ffairs E.eb E8 !usi(e, O tobe$ @, 233=F, htt):GG o%te%t-hea!tha##ai$s-o$&G &iG o%te%tGabst$a tGh!tha##-(a$-1=(0 Ea essed 2< 0<= Ma" 2303FA%%ette O9Co%%o$, Hi!a$" L!e'e!!"%6Thomas, a%d A%% +a$$" F!ood, BModi#"i%& U%'a$$a%ted La$iatio%s I% Hea!th Ca$e: Sha$ed De isio% Ma4i%& Usi%& Patie%t De isio% Aids,C (ealth ffairs E.eb E8 !usi(e, @ O tobe$ 233=F: <;6@2htt):GG o%te%t-hea!tha##ai$s-o$&G &iG$e)$i%tGh!tha##-(a$-<;(0-)d# Ea essed 2A Ma" 2303F-

<1

De isio%a! o%#!i t a% bu$de% hea!th a$e )$o(ide$s a%d abso$b o%side$ab!e amou%ts o# timePatie%ts 'ith de isio%a! o%#!i t a$e mo$e !i4e!" to s hedu!e $e)eat a))oi%tme%ts a%d o%ta t )$o(ide$s outside o# a))oi%tme%ts (ia te!e)ho%e a%d emai! #o$ additio%a! i%#o$matio%- Patie%ts ma" be !ess satis#ied 'ith the a$e the" $e ei(e, ha(e !ess o'%e$shi) o# the de isio%, #ee! disem)o'e$ed, a%d e8)e$ie% e u%%e essa$" emotio%a! o$ )s" ho!o&i a! st$ess- I% some ases, )atie%ts ma" %ot $e ei(e the t$eatme%t the" )$e#e$ o$ the" ma" be )$essu$ed i%to u%%e essa$" )$o edu$es-

The &oa!s o# i%te$(e%tio%s #o$ de isio%a! o%#!i t a$e to ad(o ate #o$ )atie%ts a%d to he!) them ma4e de isio%s that the" a% a t o%0<1

To a hie(e this, SDM uti!i5es te h%i*ues #$om o%#!i t oa hi%& a%d

mediatio%: o%#!i t a%a!"sis, )a$ti u!a$!" ide%ti#"i%& 4e" issues, sta4eho!de$s a%d u%de$!"i%& i%te$ests7 e%su$i%& )$o ess #ai$%ess7 $aisi%& a'a$e%ess o# )o'e$ imba!a% es7 $ea!it" testi%&7 a%d &e%e$ati%& o)tio%s- Sha$ed de isio% ma4i%& a% be #a i!itated b" a )$o(ide$ di$e t!" i%(o!(ed 'ith the )atie%t9s a$e team o$ b" a thi$d )a$t" ad(o ate 'ho is %ot )a$t o# !i%i a! a$e team- The %eut$a!it" to'a$ds the u!timate de isio% is a disti% t de)a$tu$e #$om the %o$ma! hea!th a$e )$o(ide$ $o!e o# $e omme%di%& o)tio%s7 this #o us o% )$o ess a%d e%su$i%& that )atie%ts ha(e the i%#o$matio% a%d 4%o'!ed&e the" %eed to ma4e a% i%#o$med de isio% a$e additio%a! o$$e!atio%s 'ith o%#!i t ma%a&eme%t-

De isio% aids a$e #$e*ue%t!" uti!i5ed to assist )atie%ts 'ith thei$ de isio%a! o%#!i ts- I% some s"stems, su h as that o# the Da$tmouth6Hit h o 4 Medi a! Ce%te$, )atie%ts dia&%osed 'ith e$tai% a% e$s a$e automati a!!" se%t de isio% aids u)o% bei%& i%#o$med o# thei$ dia&%osis-0<< P$io$ to thei$ %e8t s hedu!ed a))oi%tme%t, )atie%ts a$e e% ou$a&ed to 'o$4 th$ou&h these aids, 'hi h )$o(ide ba 4&$ou%d i%#o$matio% o% the disease a%d out!i%e a (a$iet" o# #a to$s, i% !udi%& )ote%tia! osts a%d be%e#its, i%(o!(ed 'ith the

165 Jate C!a", P$o&$am Di$e to$, Ce%te$ #o$ Sha$ed De isio% Ma4i%&, Da$tmouth6Hit h o 4 Medi a! Ce%te$, Ha%o(e$, NH, = Ma" 2303166 Autho$ i%te$(ie' 'ith Jate C!a"7 additio%a! i%#o$matio% o% the Da$tmouth6Hit h o 4 Medi a! Ce%te$ )$o&$ams is a(ai!ab!e at '''-i%#o$medmedi a!de isio%s-o$&<<

t$eatme%t o)tio%s- Idea!!" )atie%ts the% a$$i(e at thei$ a))oi%tme%t bette$ )$e)a$ed to e%&a&e mo$e *ui 4!" 'ith the most o%te%tious issues at the hea$t o# thei$ de isio% o% t$eatme%t o)tio%s-

Sha$ed de isio% ma4i%& a))$oa hes a% a hie(e a bette$ use o# !i%i a! time, as a))oi%tme%t time is s)e%t o% mo$e substa%tia! issues a%d )atie%t %eeds- O#te% the use o# de isio% aids )$io$ to a% a))oi%tme%t a!!o's )atie%ts to ma4e a di##i u!t t$eatme%t de isio% at that a))oi%tme%t, somethi%& that $a$e!" ha))e%s othe$'ise i% these o%te8ts- .hi!e SDM does o asio%a!!" sa(e time be ause it a(oids the !i%&e$i%& time si%4s asso iated 'ith de isio%a! o%#!i t E#o!!o' u) emai!s U )ho%e a!!s #$om )atie%ts 'ith u%a%s'e$ed *uestio%s, $e)eat (isitsF, t")i a!!" the time Dusti#i atio% #o$ sha$ed de isio% ma4i%& is that it a!!o's #o$ )$o(ide$ a%d )atie%t to e%&a&e at a mo$e mea%i%&#u! !e(e! a%d use thei$ time to&ethe$ to a hie(e bette$ out omes-

+e"o%d time be%e#its, sha$ed de isio% ma4i%& a% he!) a(oid u%%e essa$" t$eatme%t, es)e ia!!" su$&e$ies7 im)$o(e )atie%t 4%o'!ed&e s o$es about thei$ o%ditio%, o)tio%s #o$ t$eatme%t, a%d !i4e!" $esu!ts7 he!) )atie%ts &ai% $ea!isti out omes #o$ o)e$atio%s, a 4e" as)e t o# i%#o$med o%se%t7 $edu e !iabi!it" b" i% $easi%& )atie%t o'%e$shi) o# the de isio%7 i% $ease )atie%t satis#a tio% s o$es7 a%d he!) )$o(ide$s #ee! mo$e #u!#i!!ed be ause the" a$e bette$ ab!e to em)o'e$ )atie%ts- 0<@

The sha$ed de isio% ma4i%& mode! om)!eme%ts the i%te$%a! %eut$a! ombuds mode! as the" add$ess o%#!i t at di##e$e%t sta&es o# ma%i#estatio%- De isio%a! o%#!i t o#te% does %ot $e&iste$ as somethi%& that a )atie%t $e o&%i5es as a% u%met %eed #o$ i%#o$matio%, ommu%i atio%, o$ su))o$t- Fo$ this $easo%, a )atie%t 'ith de isio%a! o%#!i t is %ot !i4e!" to a ti(ate HCOM s"stem- +e ause )atie%ts9 e8)e tatio%s #o$ the )$o(ide$ e% ou%te$ a$e o#te% !o', the" t")i a!!" do %ot )e$ ei(e u%$eso!(ed de isio%a! o%#!i t to be a% u%a%ti i)ated

0<@

Timoth" .he!a%, et a!-, BE##e t o# a de isio% aid o% 4%o'!ed&e a%d t$eatme%t de isio% ma4i%& #o$ b$east a% e$ su$&e$": a $a%domi5ed t$ia!,C $ournal of the merican Medical ssociation 2?2, %o- = E/u!" 233=F: =;16=07 a!so7 autho$ i%te$(ie' 'ith Jate C!a", P$o&$am Di$e to$, Ce%te$ #o$ Sha$ed De isio% Ma4i%&, Da$tmouth6Hit h o 4 Medi a! Ce%te$, Ha%o(e$, NH, = Ma" 2303-

<@

out ome to om)!ai% about- I% this 'a", SDM is a #o$m o# a'a$e%ess6$aisi%& about e8)e tatio%s a%d 'hat )atie%ts dese$(e- This a% be a% e8am)!e o# a dee)e$ #o$m o# $e!atio%shi) t$a%s#o$matio%, as it !oo4s mo$e !ose!" at the &oa! o# the e% ou%te$ tha% do ma%" )atie%t6 )$o(ide$ i%te$a tio%s- It is %ot a ti(ated i% $es)o%se to a )a$ti u!a$ ad(e$se e(e%t but !oo4s to dee)e% 'hat the )atie%t $e ei(es out o# thei$ medi a! e% ou%te$-

D- Ethi s Co%#!i ts

Ethi s o%#!i ts i% hea!th a$e a$e a thi$d domai% o# dis)ute $eso!utio% i% the )atie%t6)$o(ide$ d"%ami - .hi!e disa&$eeme%ts su$$ou%di%& e%d o# !i#e de isio%s a$e a hi&h6)$o#i!e e8am)!e these t")es o# o%#!i t, additio%a! disa&$eeme%ts $outi%e!" a$ise a$ou%d the issues o# o%#ide%tia!it", $esou$ e a!!o atio%, t$a%s)a$e% ", om)eti%& i%te$ests, !o us6o#6autho$it", a%d $e)$odu ti(e a$e, amo%& othe$s- 0<A These ethi s o%#!i ts a% a$$" hi&h osts that a##e t mu!ti)!e dime%sio%s o# the hea!th a$e e%(i$o%me%t- As .i!so% )oi%ts out, the im)a ts o# ethi s o%#!i ts i% hea!th a$e )$a ti es a% i% !ude:0<?

1 Staff: a$e&i(e$ st$ess7 de#!ated mo$a!e7 'ea4e%ed )$o#essio%a!ism 2 Patients: Poo$ )atie%t satis#a tio%7 !oss o# se!#6$e#e$$a!s 3 *rgani&ation3s Culture: Dimi%ished *ua!it" o# a$e 4 Relationship with Community: Dimi%ished o$&a%i5atio%a! ima&e7 de $eased t$ust7
)oo$ )ub!i $e!atio%s7 !o'e$ !e(e!s o# )hi!a%th$o)i &i(i%&

5 Legal: I% $eased !iti&atio% a%d sett!eme%ts 6 Regulations: Ne&ati(e!" i%#!ue% es adhe$e% e to /oi%t Commissio% Sta%da$ds a%d othe$
$e&u!ato$" o$&a%i5atio%s

168 A!be$t /o%se%, Ma$4 Sie&!e$, a%d .i!!iam .i%s!ade, Clinical "thics) Practical pproach to %ecisions in Clinical Medicine- Eth ed ENe' Xo$4: M G$a'6Hi!!, 233<F7 Ruth +- Pu$ti!o, BThe Ethi a! Li#e o# Ru$a! Hea!th P$o#essio%a!s,C i% (andboo! for Rural (ealthcare "thics- ed- .i!!iam A- Ne!so% EHa%o(e$, NH: T$ustees o# Da$tmouth Co!!e&e, 233?F: ==6<2htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG#u!!6boo4-)d# Ea essed 0= Ma" 2303F169
.i!!iam A- Ne!so%, BEthi a! u% e$tai%t" a%d sta## st$ess,C (ealthcare "#ecutive 2=, %o- = E233?F: ;A6;?-

<A

1 *rgani&ation3s 4ottom Line: O)e$atio%a!, !e&a!, a%d )ub!i $e!atio%s osts

+e ause ethi s issues i% hea!th a$e a$ise 'ith #$e*ue% " a%d ha(e 'ides)$ead im)a t, it is see% as im)o$ta%t #o$ i%stitutio%s to de(e!o) s"stems #o$ )$e(e%ti(e, )$oa ti(e $es)o%ses to ethi a! u% e$tai%t" a%d !i4e!" disa&$eeme%ts, $athe$ tha% $e!"i%& o% a $ea ti(e a))$oa h- O%e om)o%e%t o# this a))$oa h is to he!) )$o(ide$s i% $ease thei$ 4%o'!ed&e a%d s4i!!s #o$ $e o&%i5i%& a%d ma%a&i%& ethi s o%#!i ts at a!! sta&es- A se o%d om)o%e%t is to )$o(ide t$ai%i%& o% o%#!i t $eso!utio% s4i!!s a%d )$o esses to bioethi s ommittees- A thi$d om)o%e%t is the de(e!o)me%t o# bioethi s mediatio% $esou$ es-

Care Providers) "arly 'nterventions

Ca$e )$o(ide$s )!a" im)o$ta%t $o!es i% ea$!" )atie%t o%(e$satio%s su$$ou%di%& ethi s o%#!i ts- To )$e)a$e )$o(ide$s #o$ these e% ou%te$s, bioethi s de isio%6ma4i%& too!s a$e 'ide!" a(ai!ab!e- 0@3 Ma%" o# these too!s attem)t to )$o(ide )$a ti a! #$ame'o$4s #o$ e(a!uati%& a%d $ea hi%& de isio%s- .hi!e these #$ame'o$4s )$o(ide substa%ti(e ethi a! &uida% e, the" o#te% do %ot e*ui) )$o(ide$s 'ith the ommu%i atio% a%d o%#!i t $eso!utio% #$ame'o$4s %e essa$" #o$ e##e ti(e ma%a&eme%t o# the ethi s o%#!i t- Amo%& othe$ o%#!i t ma%a&eme%t )$o ess s4i!!s, )$o(ide$s ma" $e*ui$e t$ai%i%& a%d )$o#essio%a! su))o$t o% ommu%i atio% i% di##i u!t o%(e$satio%s, o%#!i t a%a!"sis, ide%ti#"i%& u%de$!"i%& issues, a ti(e !iste%i%&, &$ou) #a i!itatio%, a%d a&$eeme%t ma%a&eme%t0@0

Fami!ia$it" 'ith

a% i%te$est6based %e&otiatio% mode! a% be )a$ti u!a$!" he!)#u! #o$ ide%ti#"i%& u%de$!"i%& %eeds that ma" othe$'ise be o(e$!oo4ed b" ma%" bioethi s #$ame'o$4s- The$e a$e additio%a! o))o$tu%ities #o$ mo(i%& be"o%d i%te$est6based mode!s i% o$de$ to $aise )$o(ide$s9 a'a$e%ess o# the im)o$ta% e o# t$ust, $es)e t, )a$ti i)ato$" de isio% ma4i%&, a%d ommu%i atio% i% these situatio%s-

170 Fo$ e8am)!es, see Pu$ti!o, BThe Ethi a! Li#e o# Hea!th a$e P$o#essio%a!sC7 a%d /o%se%, Sie&!e$, a%d .i%s!ade, Clinical "thics+ 171 .i!!iam A- Ne!so% a%d Ja$e% E- S hi##e$de 4e$, BP$a ti a! St$ate&ies #o$ Add$essi%& a%d P$e(e%ti%& Ethi s Issues i% Ru$a! Setti%&s,C i% (andboo! for Rural (ealthcare "thics- ed- .i!!iam A- Ne!so% EHa%o(e$, NH: T$ustees o# Da$tmouth Co!!e&e, 233?F: ;3A- htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG#u!!6boo4-)d# Ea essed 0= Ma" 2303F<?

4ioethics Committees

Re*uests #o$ bioethi s o%su!tatio%s a$e mo$e ad(a% ed ma%i#estatio%s o# the o%#!i ts that a$ise 'he% !i%i ia%s, )atie%ts, o$ #ami!" membe$s )e$ ei(e othe$ a to$s as im)edi%& thei$ &oa!s #o$ a$e o$ out omes-0@2 T$ai%i%& bioethi s o%su!ta%ts o% ommu%i atio% s4i!!s a%d o%#!i t ma%a&eme%t )$o ess s4i!!s a% im)$o(e thei$ ha%d!i%& o# these issues a%d a!so he!) them se$(e as mode!s #o$ the hos)ita! o% o!!abo$ati(e o%#!i t e%&a&eme%t-0@; This ma" i% !ude i% $easi%& o%su!ta%ts9 #ami!ia$it" 'ith #a i!itated dia!o&ue, mediatio%, o%se%sus bui!di%&, a%d )a$ti i)ato$" de isio% ma4i%& )$o esses-

.hi!e i%te$est6based %e&otiatio% mode!s a$e use#u! #o$ bioethi s o%su!tatio%s, t$a%s#o$mati(e mediatio% mode!s o)e% additio%a! o))o$tu%ities #o$ $ea hi%& dee)e$ !e(e!s o# a 4%o'!ed&eme%t a%d u%de$sta%di%& o# the %eeds o# the )a$ties to a dis)ute- The +a"state Hea!th Ca$e S"stem uses t$a%s#o$mati(e mediatio% i% thei$ bioethi s ommittee o%su!ts a%d $e*ui$es a!! ommittee membe$s to u%de$&o a =36hou$ t$a%s#o$mati(e mediatio% ou$se a%d o%&oi%& t$ai%i%&s- 0@= Fu$the$ a 4%o'!ed&eme%t o# the im)o$ta% e o# t$ust, auto%om", a%d $e o&%itio% i% bioethi s o%#!i ts ma" i% $ease the use o# t$a%s#o$mati(e mediatio% te h%i*ues-

4ioethics Mediations

.hi!e i%#o$ma! mediatio% is a% as)e t o# ma%" bioethi s o%su!tatio%s, mo$e #o$ma! bioethi s mediatio%s a$e !i4e!" o%!" a#te$ the t'o ea$!ie$ !e(e!s o# i%te$(e%tio%s E a$e )$o(ide$s a%d bioethi s ommitteesF ha(e #ai!ed to $eso!(e a dis)ute- Coo!e" a$&ues that su ess#u! bioethi s mediatio% is de)e%de%t u)o% se!e ti%&

172 Lau$e% Ede!stei%, et a!-, BCommu%i atio% a%d Co%#!i t Ma%a&eme%t T$ai%i%& #o$ C!i%i a! +ioethi s Committees,C ("C 7orum 20, %o- = EDe embe$ 233?F: ;=2Da!e Het5!e$, et a!-, BCu$i%& Co%#!i t: A )$es $i)tio% #o$ ADR i% hea!th Maga&ine 00, %o- 0 EFa!! 233=F: <-

173 174

Ede!stei% et a!-, BCommu%i atio% a%d Co%#!i t Ma%a&eme%t T$ai%i%&,C ;=2a$e,C %ispute Resolution

@3

the $i&ht mediato$ a%d uti!i5i%& the o$$e t mode! o# mediatio%- 0@1 He su&&ests that membe$s o# hos)ita! bioethi s ommittees a$e o#te% %ot the most a))$o)$iate hoi e #o$ mediato$ as the" a$e subDe t to bias a%d u%$eso!(ed )o'e$ dis)utes 'ithi% the i%stitutio%0@<

I%stead, %u$ses a%d

)atie%t ad(o ates ma" be ab!e to se$(e as mediato$s mo$e e##e ti(e!", i# t$ai%ed i% mediatio% b" bioethi s o%su!ta%ts- E8te$%a! mediato$s a% a!so be a% a))$o)$iate o)tio%, i# the mediato$ is #ami!ia$ 'ith bioethi s mediatio% a%d the !e&a! a%d ethi a! %o$ms a))!"i%& to the ase7 has su##i ie%t 4%o'!ed&e o# the admi%ist$ati(e a%d )o!iti a! dime%sio%s o# the )a$ti u!a$ hea!th a$e i%stitutio%7 a%d has su##i ie%t ba 4&$ou%d i% hea!th a$e to u%de$sta%d the issue at ha%d0@@

Coo!e" a$&ues that bioethi s mediatio% di##e$s #$om othe$ mode!s o# mediatio% be ause it is o%st$ai%ed b" $e!e(a%t !e&a! a%d ethi a! )$i% i)!es- 0@A +e ause the$e a$e $e o&%i5ed !e&a! a%d ethi a! #$ame'o$4s that sti)u!ate 'ho has the #i%a! autho$it" to de ide o% the u!timate ou$se o# a tio%, )a$t o# the mediato$9s Dob is to he!) )atie%ts, #ami!ies, a%d a$e&i(e$s )$o)e$!" ide%ti#" this )e$so%- 0@? As a $esu!t, Coo!e" a$&ues that bioethi s mediatio%s &e%e$a!!" must ado)t a $i&hts6based mediatio% mode! $athe$ tha% a% i%te$est6based mediatio% mode!- 0A3 This has si&%i#i a%t im)!i atio%s #o$ the $o!e o# the mediato$ i% the )$o ess, 'ho a%%ot #u% tio% as a #u!! %eut$a!- I%stead, the" must ad(o ate #o$ the !a's a%d ethi a! )$i% i)!es that a$e a e)ted

as a))!"i%& to the ase, i% additio% to see4i%& to meet the i%te$ests o# the )a$ties i%(o!(ed to the e8te%t )ossib!e- The mediato$ a% $emai% %eut$a! as to the out ome o%!" so !o%& as the $eso!utio% om)!ies 'ith ethi a! a%d !e&a! %o$ms a##e ti%& the ase-0A0

175 176 177 178 179 180 181

Coo!e", Coo!e", Coo!e", Coo!e", Coo!e", Coo!e",

dose of %R- 0@dose of %R- 0@dose of %R- 0@dose of %R- 0@dose of %R- 0@dose of %R- 0@-

Liebma% a%d H"ma%, Medical "rror %isclosure-C 03@-

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III/ 0atient 2 0a(er Conflicts89:

This d"%ami , o#te% $e#e$$ed to as hea!th o(e$a&e dis)utes, t")i a!!" i%(o!(e dis)utes o(e$ o(e$a&e o$ $eimbu$seme%t o# !aims-0A; Patie%t6)a"e$ o%#!i t i%te$(e%tio%s di##e$ #$om the othe$ d"%ami s i% bei%& !ess $e!atio%a! a%d mo$e t$a%sa tio%a! i% %atu$e- Co%#!i t ma%a&eme%t i%te$(e%tio%s te%d to be !a$&e!" #o used o% i%te$est6based %e&otiatio%, mediatio%, a%d ad(o a " E#o$ )atie%ts i% the #a e o# )o'e$ imba!a% es 'ith )a"e$sF-

+esides dis)utes 'ith i%su$a% e om)a%ies, )atie%t dis)utes 'ith ma%a&ed a$e )$o(ide$s a!so #a!! u%de$ this d"%ami - Patie%t dis)utes i%(o!(i%& )a"me%t a##e t ma%a&ed a$e o$&a%i5atio%s, as i% ma%a&ed a$e o$&a%i5atio%s )a"e$ a%d )$o(ide$ a$e o#te% )a$t o# the same s"stemAdditio%a!!", )atie%ts ma" ha$&e that the ma%a&ed a$e )!a% misa))!ied )$oto o!s o$ %e&!e ted a e)tab!e medi a! sta%da$ds- 0A= +e ause the$e is i% $eased o(e$!a) bet'ee% )atie%t6)$o(ide$ dis)utes a%d )atie%t6)a"e$ dis)utes i% ma%a&ed a$e )!a% o%te8ts, ma%" su h dis)utes a$e o#te% dea!t 'ith b" a% i%te$%a! %eut$a! Esu h as a% HCOMF i% !a$&e ma%a&ed a$e o$&a%i5atio%s-

Medicare beneficiary mediation- The Ce%te$s #o$ Medi a$e a%d Medi aid Se$(i es ECMSF o%t$a t 'ith Sua!it" Im)$o(eme%t O$&a%i5atio%s i% ea h state to im)!eme%t the dai!" o)e$atio%s o# Medi a$e a%d dete$mi%e 'hethe$ the se$(i es $e%de$ed as medi a!!" %e essa$" a%d a))$o)$iate-0A1 These state6based o$&a%i5atio%s a$e $e*ui$ed to o##e$ the o)tio% o# mediatio% #o$ ommu%i atio%6based )atie%t om)!ai%ts-0A<

Co%t$a ted mediato$s assist 'ith these ases, 'hi h ma" i%(o!(e o6mediatio% 'ith a )h"si ia%-

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182 The$e is a!so a $e!ated a$e%a o# o%#!i ts bet'ee% )h"si ia%s a%d )a"e$s- Ma%" o# these o%#!i ts i%(o!(e )h"si ia%s o% beha!# o# a )atie%t, he% e I ate&o$i5e them u%de$ this d"%ami - Othe$ )h"si ia% > )a"e$ dis)utes a$e &$ou)ed u%de$ the )h"si ia% > admi%ist$atio% ate&o$" o# o%#!i t183 184 185 186 187
Coo!e", Coo!e", dose of %R- 0@dose of %R- 0@-

Liebma% a%d H"ma%, Medical "rror %isclosure, 03@Het5!e$, et a!-, BCu$i%& Co%#!i t,C 16@Het5!e$, et a!-, BCu$i%& Co%#!i t,C 16@-

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Collaborative claims management- This is a% a))$oa h to )atie%t !aims uti!i5i%& ADR #$ame'o$4s #o$ $e o% i!i%& disa&$eeme%ts- Re o% i!iatio% attem)ts ma" i%(o!(e mediatio%s a%d the u!tu$e o# i%te$est6based %e&otiatio% e% ou$a&es o)e% a ess to do ume%ts a%d )e$so%%e!0AA

These

mediatio%s a% be o%du ted b" i%te$%a! %eut$a!s o$ b" $e&u!a$ bi!!i%& a%d ustome$ se$(i e sta##-

Mediation for Mental (ealth Clients- Some o$&a%i5atio%s, su h as the Dist$i t o# Co!umbia De)a$tme%t o# Me%ta! Hea!th a%d A$i5o%a State Hos)ita!, o##e$ mediatio% #o$ )atie%t om)!ai%ts0A?

Si&%i#i a%t!", this i% !udes e8)!i it e##o$ts to add$ess )o'e$ imba!a% e a%d dedi ated sta##

time to he!)i%& )atie%ts i% this )$o ess-

LongAterm care ombudsmen- As )e$ !e&is!atio%, states em)!o" ombudsme% to ad(o ate #o$ !o%&6te$m a$e $eside%ts- Additio%a!!", the" ma" o(e$see the oo$di%atio% o# (o!u%tee$ ombudsme% to ha%d!e )atie%t om)!ai%ts-0?3

Consumer dvocacy- Co%%e ti ut $eated the O##i e o# Hea!th a$e Ad(o ate EOHAF, a% i%de)e%de%t &o(e$%me%t a&e% ", to )!a" a o%sume$ ad(o a " $o!e )$ote ti%& the i%te$ests o# )eo)!e o(e$ed u%de$ ma%a&ed a$e o$&a%i5atio% hea!th )!a%s- 0?0 It edu ates o%sume$s about thei$ $i&hts a%d $es)o%sibi!ities, a%a!"5es t$e%ds, a%d ma4es )ub!i )o!i " $e omme%datio%sMo$eo(e$, the OHA a ts as a di$e t ad(o ate #o$ )o!i "ho!de$s a%d 'i!! i%te$(e%e to ho!d i%su$e$s a ou%tab!e- OHA sta## membe$s )$o(ide i%#o$matio% to o%sume$s, assist 'ith #i!i%& om)!ai%ts a%d i%te$%a! a%d e8te$%a! a))ea!s, he!) ommu%i ate 'ith i%su$e$s o% beha!# o# the )atie%ts, a%d ma" a))ea$ at admi%ist$ati(e hea$i%&s, thou&h the" do %ot $e)$ese%t )o!i "ho!de$s i% ou$t-

188 189 190 191

Het5!e$, et a!-, BCu$i%& Co%#!i t,C <Het5!e$, et a!-, BCu$i%& Co%#!i t,C <Het5!e$, et a!-, BCu$i%& Co%#!i t,C <C!a$4, BAd(o a " i% Hea!th Ca$e,C 03602-

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This i%te$(e%tio% o% beha!# o# )atie%ts is %ote'o$th" as a% attem)t to add$ess )o'e$ imba!a% es i% the i%te$a tio% bet'ee% )atie%t a%d )a"e$- The OHA ha%d!es 26;,333 ases )e$ "ea$, 'ith A1K o# the ases i%(o!(i%& )o!i " $es issio% #o$ u%dis !osed i%#o$matio%- 0?2 A o$di%& to the state hea!th a$e ad(o ate, !ess tha% 03K Co%%e ti ut )o!i "ho!de$s a))ea! the de%ia! o# a !aim, so i% $easi%& a'a$e%ess about the a(ai!ab!e ad(o ate $esou$ es is a 4e" #o us0?;

Additio%a!!", )h"si ia%s a%

tu$% to the OHA 'he% 'o$4i%& o% beha!# o# a )atie%t to &et a de%ia! o(e$tu$%ed-

.hi!e the ha%&i%& !a%ds a)e o# US hea!th a$e 'i!! o%ti%ue to shi#t the detai!s, ad(o a " i%te$(e%tio%s aimed at add$essi%& )o'e$ imba!a% es i% the )atie%t > )a"e$ d"%ami a$e a% im)o$ta%t a))!i atio% o# o%#!i t $eso!utio% i% hea!th a$e-

I./ 0ro1ider 2 Administration Conflicts

P$o(ide$ > admi%ist$atio% o%#!i ts $a%&e #$om t$aditio%a! 'o$4)!a e a%d !abo$ > ma%a&eme%t dis)utes to se$ious )o'e$ st$u&&!es a%d dest$u ti(e $e!atio%s that a% )o!!ute e%ti$e 'o$4)!a es-0?= A &$o'i%& !ite$atu$e do ume%ts om)etitio% a%d ad(e$sa$ia! $e!atio%s bet'ee% )h"si ia%s a%d admi%ist$ato$s that a% #ue! bitte$ a%d e%t$e% hed o%#!i t i% hea!th a$e e%(i$o%me%ts-0?1 These o%#!i ts a% a$ise #$om di##e$e%t )$o#essio%a!

192

C!a$4 des $ibes a ommo% o%te8t o# )o!i " $es issio%: BA% i%di(idua! )u$ hases a hea!th i%su$a% e )o!i ", )a"s

)$emiums, &ets si 4, a%d submits a !aim, to 'hi h a a$$ie$ $es)o%ds 'ith $es issio%- The )o!i "ho!de$ is i%#o$med that the de isio% to $es i%d is based o% the i%su$e$9s dete$mi%atio% that, had )a$ti u!a$ i%#o$matio% bee% dis !osed, the )o!i " 'ou!d %ot ha(e bee% '$itte%-C C!a$4, BAd(o a " i% Hea!th Ca$e,C 03-

This i% !udes !i%i ia% em)!o"me%t o%t$a ts a%d te$ms, dis $imi%atio%, 'o$4i%& )$o#essio%a! $e!atio%s, a%d i%t$a6o$&a%i5atio%a! issues- Coo!e", dose of %R- 0A-

193 194

C!a$4, BAd(o a " i% Hea!th Ca$e,C 03o%ditio%s, i%te$6

195 See es)e ia!!" the '$iti%&s o# Je%%eth Coh%: Je%%eth Coh% a%d Mi hae! Peet5, BSu$&eo% F$ust$atio%: Co%tem)o$a$" P$ob!ems, P$a ti a! So!utio%s,C Contemporary Surgery 1?, %o- 2 EFeb 233;F: @<6A17 Je%%eth Coh%, Leo%a$d F$iedma%, a%d Thomas A!!"%, BThe Te to%i P!ates a$e Shi#ti%&: Cu!tu$a! Cha%&e (s- Mu$a! D"s!e8ia,C 7rontiers of (ealth Services Management 2=, %o- 0 EFa!! 233@F: 0062<7 Je%%eth Coh%, +$u e +etha% ou$t, a%d Mai$e Simi%&to%, BThe Li#e!o%& Ite$ati(e P$o ess o# Ph"si ia% Rete%tio%,C $ournal of (ealthcare Management 1=, %o- = E/u!"GAu&ust 233?F: 223622<7 Je%%eth Coh%, BMedi a! Sta## @=

u!tu$es, edu atio%a! ba 4&$ou%ds, )o'e$ hie$a$ hies, i% om)!ete a ess to i%#o$matio%, ommu%i atio% b$ea4do'%s, om)eti%& $es)o%sibi!ities, a%d )e$ e)tio%s that the )$o#essio%s ho!d di(e$&e%t (a!ues-

To dees a!ate ad(e$sa$ia! $e!atio%s bet'ee% )h"si ia%s a%d admi%ist$ato$s, Coh% a%d Peet5 su&&est i% $eased #o us o% ommu%i atio% s4i!!s, dea!i%& 'ith emotio%, team bui!di%&, o!!abo$ati(e )$ob!em so!(i%&, )a$ti i)ato$" !eade$shi), a%d o%se%sus bui!di%&- 0?< The" su&&est that su ess#u!!" ma%a&ed o%#!i t B !ea$s u) misu%de$sta%di%&, de $eases a%&e$ a%d

$ese%tme%t, hei&hte%s u%de$sta%di%&, a%d #oste$s the de(e!o)me%t o# i%%o(ati(e se$(i es #o$ )atie%ts a%d im)$o(ed su$&eo%s9 a%d hos)ita!s9 sta%di%& i% the ommu%it"-C 0?@

Coh%, F$iedma%, a%d A!!"% ad(o ate th$ee additio%a! te h%i*ues #o$ o(e$ omi%& the o%#!i ts that $esu!t #$om de#e%si(e $easo%i%& a%d e%t$e% hed )ositio%s- 0?A Structured dialogue $eates a #o$um #o$ )$a ti i%& )h"si ia%s to a$ti u!ate !i%i a! )$io$ities to hea!th a$e admi%ist$ato$s i% a st$u tu$ed )$o ess based o% o%se%sus bui!di%& a%d )a$ti i)ato$" )$ob!em so!(i%&- ppreciative in<uiry $e#$ames $e!atio%shi)s a%d $eo$ie%ts to'a$ds the #utu$e to bui!d o% su esses $athe$ tha% $emai% #i8ated o% $oot6 ause a%a!"ses o# )$ob!ems- Positive deviance as a method #o$ o(e$ omi%& )$ob!ems see4s to )$omote o'%e$shi) o# ha%&e b" #i%di%& so!utio%s that a!$ead" e8ist i% the ommu%it" i%stead o# im)o$ti%& )$a ti es #$om outside- Coh% a%d othe$s $e)o$t these st$ate&ies a% be uti!i5ed i% a% o(e$a$ hi%& o%#!i t $eso!utio% #$ame'o$4 'ith o%side$ab!e su ess-

Ma%" i%te$(e%tio%s i% the )$o(ide$ > admi%ist$atio% d"%ami i%(o!(e t$aditio%a! !abo$ > ma%a&eme%t dis)utesMediatio% is #$e*ue%t!" used to $eso!(e disa&$eeme%ts $e&a$di%& em)!o"ee o)e$atio%s, huma%

Re!atio%s,C San %iego Physician+org E/u%e 233AF: 2=6;27 Je%%eth Coh%, Thomas A!!"%, a%d Robe$t Reid, BSt$u tu$ed Dia!o&ue +et'ee% Ph"si ia%s a%d Admi%ist$ato$s Xie!ds Positi(e Resu!ts,C The Physician "#ecutive E/u!"GAu&ust 233<F: 22621-

196 197 198

Coh% a%d Peet5, BSu$&eo% F$ust$atio%,C @<6A1Coh% a%d Peet5, BSu$&eo% F$ust$atio%,C A;Coh%, F$iedma%, a%d A!!"%, BThe Te to%i P!ates a$e Shi#ti%&,C 0062<-

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$esou$ es om)!ai%ts, u%io% %e&otiatio%s, a%d o%t$a t ba$&ai%i%&-0?? O$&a%i5atio%s o#te% em)!o" a (a$iet" o# i%te$%a! Eombuds, Ma%a&eme%t Re(ie' Committee, a%d e8e uti(e desi&%ated as a$bite$F a%d e8te$%a! Emediatio% a%d a$bit$atio%F dis)ute $eso!utio% i%te$(e%tio%s to dea! 'ith these dis)utes- 233

As the $e!atio%shi)s bet'ee% hea!th a$e i%stitutio%s, )a"e$s, a%d )$o(ide$s o%ti%ue to e(o!(e, ha%&es $esu!ti%& #$om me$&e$s, shi#ti%& a!!ia% es, a%d %e' o$&a%i5atio%a! s"stems a% !ead to a ate&o$" o# disa&$eeme%ts a!!ed Bdisa##i!iatio% dis)utes-C E8am)!es o# disa##i!iatio% dis)utes i% !ude i% ide%ts 'he% a )$o(ide$ is $e!eased #$om a )$a ti e &$ou) due to )h"si ia%6 om)ete% " o% e$%s, is e8 !uded #$om a %e'!"6#o$med )$o(ide$ &$ou) o$ ma%a&ed a$e o$&a%i5atio%, o$ is %ot desi&%ated as a% e!i&ib!e )$o(ide$ #o$ a e$tai% i%su$a% e )!a%-230 These dis)utes o#te% a$$" si&%i#i a%t #i%a% ia! o%se*ue% es #o$ hea!th a$e )$o(ide$s, th$eate% )$o#essio%a! $e)utatio%s, a%d i%(o!(e hi&h emotio%s- 232

Some o# these ases a% be e##e ti(e!" sett!ed th$ou&h mediatio%, as mediatio% a% o#te% ha%d!e the emotio%a! a%d $e)utatio%a! e!eme%ts o# dis)utes bette$ tha% !iti&atio%- Mediatio% as a *ui 4e$, *uiete$, a%d hea)e$ o)tio% is a!so a))ea!i%& to ma%" )a$ties- Ho'e(e$, si&%i#i a%t )o'e$ imba!a% es Esu h as a !o%e )h"si ia% (e$sus a !a$&e o$)o$ate )$o(ide$F a%d di##e$e%t )e$ e)tio%s o# o%#!i t $i)e%ess a% a##e t the a))$o)$iate%ess o# mediatio% i% su h ases-

Fi%a!!", )$o(ide$ > admi%ist$atio% o%#!i ts o#te% a$ise o(e$ $esou$ e a!!o atio% de isio%s- These dis)utes a% i%(o!(e o%#!i ts bet'ee% om)eti%& (a!ues: )e$so%a!, )$o#essio%a!, o$&a%i5atio%a!, a%d ommu%it"-23;
Di##i u!t $esou$ e a!!o atio% de isio%s )ose si&%i#i a%t ommu%i atio% ha!!e%&es a%d a$e )$ime &$ou%ds

199 200 201 202 203

Het5!e$, et a!-, BCu$i%& Co%#!i t,C <Coo!e", Coo!e", Coo!e", dose of %R- 0Adose of %R- 0@dose of %R- 0@-

Pau! +- Ga$de%t a%d Susa% A- Ree(es, BEthi s Co%#!i ts i% Ru$a! Commu%ities: A!!o atio% o# S a$ e

Resou$ es,C i% (andboo! for Rural (ealthcare "thics- ed- .i!!iam A- Ne!so% EHa%o(e$, NH: T$ustees o# Da$tmouth Co!!e&eF: 0<?- htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG#u!!6boo4-)d# Ea essed 0= Ma" 2303F-

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#o$ o%#!i ts- E##e ti(e!" add$essi%& disa&$eeme%ts i% this o%te8t o#te% $e*ui$es s4i!! i% ide%ti#"i%& a%d #a i!itati%& a )$o ess that is #ai$, i% !usi(e, a%d t$a%s)a$e%t- The a)a it" to %a(i&ate o%te%tious issues a%d #ee!i%&s is im)o$ta%t-23=

23=

Ga$de%t a%d Ree(es, BEthi s Co%#!i ts,C 0@=-

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I!TE".IE% "ESULTS

Ni%e se)a$ate i%te$(ie's 'e$e o%du ted 'ith te% i%te$(ie'ees- T'o i%te$(ie'ees 'e$e to&ethe$ #o$ busi%ess )u$)oses at the time o# the s hedu!ed i%te$(ie', a%d the" e!e ted to )$o(ide thei$ i%te$(ie' $es)o%ses to&ethe$ i% a si%&!e emai!-

The i%te$(ie's did ide%ti#" de#i%itio%s o# su ess, but the$e 'as !ess (a$iatio% o% this to)i tha% e8)e ted- A ommo% o$e o# #i(e u%de$!"i%& met$i s 4e)t $e u$$i%&: #i%a% ia! im)a t7 time sa(i%&s7 )atie%t sa#et"G !i%i a! out omes7 )atie%t satis#a tio%7 a%d sta## mo$a!eG$ete%tio%- Redu tio%s i% !a'suits a%d )$ote tio% o# )$o#essio%a! $e)utatio% E#e'e$ om)!ai%ts #i!ed a&ai%st !i%i ia%F a!so 'e$e $e)eated b" mu!ti)!e i%te$(ie'ees- The$e 'e$e di##e$e% es i% em)hasis that $ou&h!" o$$e!ated 'ith the )$o#essio%a! $es)o%sibi!ities o# the i%te$(ie'ee, 'ith some de#i%itio%s o# su ess #o usi%& mo$e o% mo%e", othe$s o% )atie%t out omes- Ma%" i%te$(ie'ees #e!t the u!timate de#i%itio%s o# su ess 'i!! $est i% mai%tai%i%& a%d $e)ai$i%& $e!atio%shi)s a%d the$e#o$e i%(o!(e *ua!itati(e measu$eme%ts o# su ess E#ee!i%&s, )e$ e)tio%s, ha))i%ess, mo$a!e, !e&a ", #ea$G om#o$t, ommu%i atio%, atmos)he$eF

Research Challenges: Cha!!e%&es #a ed i% this $esea$ h i% !uded !a 4 o# a ess to hea!th a$e o$&a%i5atio%s9 i%te$%a! do ume%tatio% des $ibi%& u%de$!"i%& o%#!i t ma%a&eme%t s"stem desi&% )$i% i)!es, )e$#o$ma% e i%di ato$s, data o!!e ted, a%d measu$eme%ts o# su ess- A ess to su h

do ume%tatio% 'ou!d be %e essa$" #o$ s"stemati a!!" om)a$i%& de#i%itio%s o# su ess a $oss o%#!i t ma%a&eme%t s"stems i% (a$ious hea!th a$e o$&a%i5atio%s-

.hi!e $es)o%se $ates to i%(itatio%s to )a$ti i)ate i% the $esea$ h i%te$(ie's 'e$e o(e$a!! hi&h, %o $es)o%se 'as $e ei(ed #$om %ume$ous a ademi s a%d )$i(ate )$a titio%e$s i%(ited to )a$ti i)ateAdditio%a!!", I 'as u%ab!e to o%ta t $e)$ese%tati(es #$om &o(e$%me%t o$ a asso iated 'ith hea!th a$e o%#!i t$editi%& bodies

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Limitations: The si5e o# the i%te$(ie' )oo! 'as (e$" sma!! so e8t$a)o!ati%& #$om i%te$(ie' omme%ts is %ot a))$o)$iate- The se!e tio% o# th$ee i%itia! i%te$(ie'ees based o% o%(e%ie% e sam)!i%& E$athe$ tha% ide%ti#ied based o% )ub!ished !ite$atu$eF did %ot #o!!o' the $esea$ h desi&% )$oto o!s, a!thou&h it did add si&%i#i a%t (a!ue i% b$i%&i%& %oti eab!" di##e$e%t )e$s)e ti(es i%to the i%te$(ie's- I% #utu$e $esea$ h, the sam)!i%& methodo!o&" shou!d be ada)ted to $e#!e t the im)o$ta% e o# &athe$i%& )e$s)e ti(es #$om di(e$se sou$ es: o%#!i t ma%a&eme%t e8)e$ts a%d !a" )eo)!e7 adhe$e%ts a%d s4e)ti s7 a%d )ub!ishi%& a%d %o%6)ub!ishi%& )$a titio%e$s-

'nterview 7indings

The #o!!o'i%& tab!e !ists the i%te$(ie'ees9 omme%ts b$o4e% do'% b" to)i :

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Tab!e 2- I%te$(ie' Fi%di%&s

Inter1ie3ee #escription Ph"si ia%, Hos)ita! #ispute #(namic #iscussed Nu$se6)h"si ia% Eusuo(e$ dia&%osis o# )atie%t a%d t$eatme%t )!a%F $oals for Conflict Management Head o## disa&$eeme%ts i% $ea! time, be#o$e a%" di##e$e% e o# o)i%io% &ets to be a )$ob!em Use di##e$e% e i% )e$s)e ti(e to e(e$"o%e9s ad(a%ta&e Esou$ e o# %e' i%#o$matio%, im)- #o$ )atie%t sa#et" U *ua!it" o# a$eF A(oid a ti(ati%& om)!ai%t me ha%ism Hi&he$ )atie%t satis#a tio% s o$es I% $eased e##i ie% " Success Indicators Im)$o(ed *ua!it" o# )atie%t a$e Conflict Costs ; C&allenges Training Comments Mode!i%& &ood ommu%i atio% s4i!!s is 4e" Ei# see th$ou&hout medi a! s hoo! a%d $eside% " W !ate$ omes %atu$a!!"F Ot&er BGood ommu%i atio%C 'as 4e" te$m Ea$!" i%te$(e%tio% most im)o$ta%t

Im)$o(ed sta## mo$a!e

Ph"si ia%6Ph"si ia% Eusumis ommu%i atio% o(e$ )ho%e about u$&e% " o# a ase 'he% see4i%& o%su!t #$om s)e ia!istF Ph"si ia%6o(e$si&ht sta%da$dsG&o(e$%me %t $e&u!atio%s boa$ds Eim)$a ti a! sta%da$ds7 mis ommu%i atio% o% u!timate &oa!s7 %o #eedba 4 me ha%ismF

Redu ed !iabi!it"

Inter1ie3ee #escription C$iti a! Ca$e Nu$se, A ademi Medi a! Ce%te$

#ispute #(namic #iscussed Dis)utes 'ithi% medi a! team E%u$se6do to$7 do to$6do to$F Medi a! team > #ami!ies o# si 4 )atie%ts Medi a! team 6 )atie%t

$oals for Conflict Management Dis)utes 'ithi% Medi a! Team: Reso!(e )$ob!em ea$!" a%d i%te$%a!!" b" ste))i%& outside o# the $oom Medi a! team > PtHo%o$ )atie%t9s 'ishes 'hi!e he!)i%& them be i%#o$med about $e omme%ded t$eatme%t o)tio%s Sua!it" o# a$e G medi a! out ome Ei% !udes om)!ia% e 'ith medi atio% $e&ime%F Ho%o$ )atie%t9s 'ishes b" bei%& a )$o)e$ ad(o ate Fami!" om#o$tab!e 'ith ou$se o# t$eatme%t Liste% to )atie%t7 !et them te!! thei$ sto$"7 do%9t $ush them A 4%o'!ed&e sto$"G#ee!i%&s

Success Indicators I% $eased e##i ie% " Im)$o(ed *ua!it" o# a$e Mo$e )!easa%t 'o$4 e%(i$o%me%t Ho%o$ed )atie%ts9 'ishes Fami!" satis#ied 'ith de isio%

Conflict Costs ; C&allenge s U%ma%a&ed dis)utes s!o' do'% )atie%t #!o' a%d ause tas4s to ba 4 u)

Training Comments Re e%t %u$si%& Bu%it edu atio% t$ai%i%&C i% de)thad =36mi%ute t$ai%i%& o% o%#!i t $eso!utio%7 $e ei(ed CE hou$s #o$ this

Ot&er

Peo)!e 'a%t to #ee! !iste%ed to a%d $es)e ted i% thei$ 'o$4)!a e Patie%t a$e dis)utes &o u) th$ou&h Sua!it" Co%t$o! i%#$ast$u tu$e Sta## dis)utes &o u) th$ou&h %u$se ma%a&e$ ha%%e! to HR Com)!ai%t #eedba 4 me ha%isms im)$o(e *ua!it" o# a$e b )$om)t ha%&es i% )$oto o!s

Ph"si ia%, Hos)ita!7 Patie%t Com)!ai%t Liaiso% Ph"si ia% #o$ )$a ti e &$ou)

Patie%t > P$o(ide$ dis)utes Eusuom)!ai%t o(e$ i%te$a tio% 'ith )h"si ia% o$ %u$se7 out ome o# (isit7 o$ bi!!F

Patie%t satis#ied 'ith out ome o# )$ob!em6so!(i%& o%(e$satio%

BPoo$ ommu%i atio %, mis ommu%i ati o%, a%d %o ommu%i atio %C

BGood Commu%i atio%C 'as 4e" te$m used th$ou&hout o%(e$satio%

Rea!it" Che 4 )atie%t As Patie%t Com)!ai%t Liaiso% Ph"si ia% #o$ )$a ti e &$ou), usua!!" i%te$a ts (ia te!e)ho%e 'ith a%&$" )atie%ts [ e8)e tatio%s I%#o$matio% sha$i%& E)$o(ide #u!!e$ )i tu$e o# 'hat )h"si ia% 'as doi%& a%d ' h " F P$ob!em6so!(e to meet )atie%t9s %eeds

I% $eased )t satis#a tio% $ates Redu ed %umbe$ o# ma!)$a ti e ases

a$e the mai% )$ob!ems !eadi%& to dis)utes

Patie%t om)!ai%ts o!!e ted (ia hos)ita! busi%ess o##i e, *ua!it" ma%a&eme%t o##i e, o$ di$e t a!! to )$a ti e

o%e 'ee4 a#te$ om)!ai%t is #i!ed

BDoi%& the $i&ht thi%&C Im)$o(ed *ua!it" o# a$e Im)$o(ed ommu%i atio%

&$ou)Ro!e o# !iaiso% )h"si ia% (e$" simi!a$ to mediato$9s $o!e thou&h %ot %eut$a! a%d te$mi%o!o&" is (e$" di##e$e%t

A0

Inter1ie3ee #escription Nu$se, Ma%a&e$ o# hos)ita! sha$ed de isio% ma4i%& )$o&$am

#ispute #(namic #iscussed Ethi s Dis)utes Ee%d6 o#6 !i#e de isio%sF

$oals for Conflict Management +ette$ use o# time E)$o(ide$ time 'ith )atie%t s)e%t o% mo$e substa%ti(e issues a%d )atie%t %eedsF He!) )atie%ts ma4e de isio%s i% !i%e 'ith thei$ (a!ues a%d )$e#e$e% es He!) )atie%t ha(e o'%e$shi) o# de isio%

Success Indicators Patie%t ab!e to ma4e a de isio% the" a$e om#o$tab!e 'ith Eo'%e$shi) o# de isio%F a%d a t o% it U%%e essa$" t$eatme%t a(oided Patie%t has $ea!isti e8)e tatio%s #o$ t$eatme%t out omes o# o)tio%s P$o(ide$s #ee! mo$e #u!#i!!ed

Conflict Costs ; C&allenge s De isio%a! o%#!i t adds time G tas4s to %u$ses U )h"si ia%s

Training Comments

Ot&er Need ha%&e a&e%ts at a!! !e(e!s +a$$ie$s: Hie$a$ hi a! )$ob!ems ma" )$e(e%t im)!eme%tatio% i# %o su))o$t #$om su)e$io$s7 !a 4 o# time7 !a 4 o# $eimbu$seme%t #o$ time s)e%t o% this7 !a 4 o# $e o&%itio% o# )$e#e$e% e se%siti(e de isio%s7 i%su##i ie%t o!!abo$atio% o# hea!th a$e teamF

Patie%t > Fami!" 6 P$o(ide$

Most )atie%t de isio%a! o%#!i t %ot add$essed Pts- do%9t $e ei(e the t$eatme%t the" )$e#e$ Pts)$essu$ed i%to u%%e essa$" t$eatme%ts E ostF

Em)o'e$ )atie%ts A(oid u%%e essa$" t$eatme%t Im)$o(e )atie%t 4%o'!ed&e about t$eatme%t o)tio%s

A2

Inter1ie3ee #escription Ph"si ia%, Hea!th a$e Ma%a&eme%t Co%su!ta%t

#ispute #(namic #iscussed Ph"si ia% > Admi% Ph"si ia% 6 Ph"si ia%

$oals for Conflict Management He!) )h"si ia%s dea! 'ith o%#!i t a%d o%#$o%tatio% He!) )eo)!e $e o&%i5e that di##e$e% es a$e a )ositi(e #o$ e that $eates i%%o(atio% a%d im)$o(eme%t Emb$a e om)!e8it" b it im)$o(es ou$ u%de$sta%di%& +ette$ ommu%i atio% E!ead to !ess #$ust$atio%7 time sa(i%&sF

Success Indicators

Time sa(i%&s Ei% $ease e##i ie% "F

Conflict Costs ; C&allenge s Ma%" )h"si ia%s st$u&&!e to admit the" %eed he!) dea!i%& 'ith

Training Comments I%t$odu i%& ommu%i atio%6 #o used t$ai%i%&s i%to medi a! s hoo!s ma" %ot be a hi&h )$io$it" #o$

Ot&er

BGood ommu%i atio%C a%d B)$o ess s4i!!sC 'e$e 4e" $e u$$i%& te$ms Need mo$e $esea$ h o% ausa! !i%4s U !o%&6 te$m be%e#its o# &ood ommu%i atio% U )$o ess s4i!!s

Lo'e$ e8)e%ses

o%#!i ts A ou%tab!e a$e o$&a%i5atio%s dema%d mo$e o!!abo$ate 'o$4 a $oss se to$s, 'hi h $e*ui$es bette$ a%d mo$e ommu%i atio %

Hi&he$ i% omes +ette$ !i%i a! out omes

ma%" s hoo!s Sta$t o# medi a! i%te$%shi) "ea$ is o))o$tu%it" to i%t$odu e )$o ess s4i!!s t$ai%i%&

Im)$o(ed )atie%t satis#a tio% s o$es Im)$o(ed $e!atio%s

Mode!i%& o# &ood ommu%i atio% b" se%io$ )h"si ia%s i%

Im)$o(ed o!!abo$atio% o# hea!th a$e )$o(ide$s a $oss se to$s

bet'ee% hos)ita! admi%ist$ato$s a%d )h"si ia%s QDesi$e mo$e data $ei%#o$ i%& these !i%4sR

Need to o!!e t sto$ies a%d ases #o$ use i% t$ai%i%&s Must sho' that !o%&6te$m be%e#its out'ei&h sho$t6 te$m osts o# atte%di%& t$ai%i%&

tea hi%& setti%&s is im)o$ta%t Loo4 #o$ se%io$ )h"si ia% ham)io%s 'ho a% se$(e as $o!e mode!s E#o$ $eside%ts, Du%io$ )h"si ia%sF o% ommu%i atio% U )$o ess s4i!!s b"

Redu e medi a! !iti&atio%

Ph"si ia%s moti(ated to atte%d t$ai%i%&s due to mo%e", !e&a ", Dob at sta4e, et -

ta))i%& i%to a&i%& )h"si ia%s9 desi$e to !ea(e a )ositi(e !e&a "

A;

Inter1ie3ee #escription So ia! .o$4e$ EPs" ho!o&istF, Pediat$i Hos)ita!

#ispute #(namic #iscussed P$o(ide$ 6 P$o(ide$

$oals for Conflict Management Ha%d!e )$o(ide$ > )$o(ide$ dis)utes ea$!" U 'ithi% the team be#o$e HR &ets i%(o!(ed

Success Indicators Dis)ute add$essed a%d e##e ti(e!" ma%a&ed at ea$!" sta&e

Conflict Costs ; C&allenge s Sta## dis)utes a$e dis$u)ti(e

Training Comments Co%#!i t oa hi%& s4i!!s im)o$ta%t T$ai% su)e$(iso$s to me%to$ G ad(ise o% &ood o%#!i t ma%a&eme%t Ea$!" )hase

Ot&er S"stemati5e a'a$e%ess o# o%#!i t $eso!utio% st$u tu$es G o)tio%s

Patie%t > P$o(ide$

Fami!" o# )atie%t 6 P$o(ide$

Less dis$u)tio% i% 'o$4 e%(i$o%me%t

Dis)ute $eso!(ed i%te$%a!!" E'ithi%

Getti%& HR i%(o!(ed ma4es thi%&s mess"

Im)$o(ed e##i ie% " A(oid mobi!i5i%& ethi s ommittee u%%e essa$i!" Co!!abo$ate 'ith )a$e%ts o# si 4 hi!d$e% o% a$e G t$eatme%t o)tio%s

hea!th a$e teamF HR is %ot i%(o!(ed Res)e ted )atie%t 'ishes E#o$ dis)utes bet'ee% )atie%t > )$o(ide$ $emedi ati%& )s" hiat$i )atie%tsF i%te$(e%tio%s a$e im)o$ta%t

Ho!d 'ee4!" meeti%&s 'ith su)e$(iso$7 use this #o$um to dis uss ases, )$ob!ems, et -, i% !udi%& ea$!" i%te$(e%tio% o)tio%s Su)e$(iso$s a%d su)e$(isees must 4%o' the" a% use these meeti%&s to dis uss ad(i e #o$ o%#!i ts Mo$bidit" a%d Mo$ta!it" $ou%ds o)tio% #o$ a%a!"5i%& ase 'ith )atie%t dis)ute

A=

Inter1ie3ee #escription Hea!th a$e ADR P$o#essio%a!, Co%su!ta%t

#ispute #(namic #iscussed P$o(ide$ > P$o(ide$

$oals for Conflict Management Im)$o(e G $esto$e $e!atio%shi)s Redu e %e&ati(e im)a ts o# o%#!i t Etime, mo%e", emotio%a! st$ess, dama&ed $e!atio%shi)sF Desi&% mi%ima!!"6 dis$u)ti(e o%#!i t ma%a&eme%t i%te$(e%tio%s

Success Indicators

Conflict Costs ; C&allenge s Dis$u)ti(e beha(io$ im)a ts o% )atie%t sa#et" a%d $ete%tio%

Training Comments T$ai%i%&s do%9t so!(e o%#!i ts

Ot&er

De#i%itio%s o# su ess (a$" si&%i#i a%t!": Sta## satis#a tio%, ha))ie$ 'o$4 e%(i$o%me%t, !o'e$ tu$%o(e$, )eo)!e #ee! mo$e om#o$tab!e )a$ti i)ati%& a%d s)ea4i%& out, et Must as4 )a$ties at be&i%%i%& o# e(e$" i%te$(e%tio%, B.hat is "ou$ de#i%itio% o# su ess #o$ this

Shi#t a'a" #$om i%te$est6based %e&otiatio% to'a$ds

Embed o%#!i t t$ai%i%& i% medi a! u!tu$e o# see o%e, do o%e, tea h o%e Use t$ai%i%&s to $oss si!os Im)o$ta%t that ommu%i atio% s4i!!s t$ai%i%& %o' $e*ui$ed #o$ M-Dboa$d e8ams a%d $eside% " )$o&$ams T$ai%i%& ba$$ie$s: time, #u%di%&, %eed #o$ $e)eat t$ai%i%&s, !o&isti s o# &etti%& e%ti$e sta## to t$ai%i%&s Se!e tio% o# t$ai%e$

$e!atio%shi) mode!s Need both *ua!itati(e a%d *ua%titati(e data Must de(e!o) o%#!i t om)ete% e #o$ !eade$shi) Mat h hea!th a$e u!tu$e o# Do No Ha$m

i%te$a tio% G )$o&$amIC Ma%" de#i%itio%s o# su ess a$e ha$d to *ua%ti#": B.e a$e ha))"C B.e #ee! &ood about the )$o essC B.e $esto$e the

Li%4 o%#!i t ma%a&eme%t #ie!d 'ith om)!e8 s"stems $esea$ h Measu$e a tua! osts o# o%#!i t Ei% timeG mo%e"F I%te%tio%a! Me%to$shi)G mode!i%&

$e!atio%shi)C +e o%s ious o# %eed to t$a 4 im)$o(eme%ts i% $e!atio%shi)s that ma" be ha$d to measu$e

im)o$ta%t

$e!atio%shi)s im)o$ta%t )a$t o# o%#!i t e%&a&eme%t t$ai%i%&

A1

Inter1ie3ee #escription Hea!th La'"e$ G ADR P$o#essio%a!, Co%su!ta%t

#ispute #(namic #iscussed Patie%t > P$o(ide$ Ees)e ia!!" !e&a!F

$oals for Conflict Management BSuiete$, *ui 4e$, hea)e$C P$ese$(e $e!atio%shi)s

Success Indicators Fe'e$ !a'suits Fe'e$ med sta## $ede%tia!i%&

Conflict Costs ; C&allenges

Training Comments Ne8t ste)s i% t$ai%i%&: t$ai%i%& #o$ both medi a! a%d !e&a! )$o#essio%a! s, )e$ha)s o!!abo$ati( e! " Edu atio% i% &$aduate t$ai%i%&: !a' s hoo!s, med s hoo!s, %u$si%& s hoo!s, MHA )$o&$ams

Ot&er P$omotio% o# o%#!i t ma%a&eme%t: .o%9t a))ea! to a!!7 be&i% 'ith medi a! sta## mode$ates Edu ate hos)ita! admi%ist$ato$s Edu ate $is4 ma%a&e$s Edu ate hea!th !a' )$o(ide$s Use a%e dotes to i!!ust$ate (a!ue o# o%#!i t ma%a&eme%t E'ith s4e)ti sF

P$o(ide$ 6 P$o(ide$ Add$ess o%#!i ts E$athe$ tha% i&%o$e a%d !et them $adiateF Add$ess o%#!i t B'ithi% "ou$ o'% u!tu$eC E o%t$o! o# out omeF

dis)utes

Fe'e$ )atie%t om)!ai%ts to Ris4 Ma%a&eme%t Fe'e$ em)!o"ee

A hie(e 'i%6'i% so!utio%, %ot a)itu!atio%

om)!ai%ts G &$ie(a% es to HR Less tu$%6o(e$, mo$e stab!e %u$si%& sta##

A<

Inter1ie3ee #escription Hea!th a$e ADR )$o#essio%a! em)!o"ed b" hea!th o$&a%i5atio%

#ispute #(namic #iscussed Patie%t > P$o(ide$ Es)e i#i a!!" u%a%ti i)ated out omesF

$oals for Conflict Management Ha%d!e e$$o$s 'ith om)assio%ate t$eatme%t o# a!! i%(o!(ed

Success Indicators 033K t$a%s)a$e% " i% $es)o%se to ad(e$se out ome E#u!! a ess b" )atie%ts G )$o(ide$sF P$o(ide$ G sta## satis#a tio% s o$es Qi%te$%a! )e$ e)tio% o# ho' $es)o%se 'as ha%d!edR The" do %ot t$a 4 )atie%t satis#a tio% s o$es to a(oid t$i&&e$i%& emotio%a! )ai% G su$(e" #ati&ue Cost a%d !iti&atio% $ates a$e %ot used to measu$e su ess7 o(e$a$ hi%& theme is Bto do the $i&ht thi%&C C!aim ma%"

Conflict Costs ; C&allenges

Training Comments T$ai%i%& o% ad(e$se out ome dis !osu$e shou!d tea h )$o(ide$s ho' to be ho%est, t$a%s)a$e%t, a%d om)assio%ate i% these o%(e$satio%s7 ho' to )$e) #o$ the o%(e$satio%s7 %eed mu!ti)!e t$ai%i%&s Need di##e$e%t t")es o# t$ai%i%&s #o$ )eo)!e i% di##e$e%t $o!es o# the $es)o%se

Ot&er I% $easi%&!" e% ou$a&e )atie%t a%d #ami!" )a$ti i)atio% i% $oot ause a%a!"sis )$o ess

Ethi a!!" do the $i&ht thi%& #o$ )atie%ts Su))o$t )atie%ts, thei$ #ami!ies, a%d )$o(ide$s #o!!o'i%& ad(e$se out ome A(oid $e)utatio%a! )$ob!ems #o$ )$o(ide$sG#a i!it" A(oid (isits #$om DHHS o$ /oi%t Commissio% A(oid !osi%& )atie%ts

BSta## dis)utesC ha%d!ed b" di##e$e%t me ha%ism #$om )atie%t > )$o(ide$ dis)utes Em)!o"ee issues t")i a!!" $e!ated to emotio%a! )$ob!ems Est$ess, bu$%out, et F Uti!i5e di##e$e%t o%#!i t ma%a&eme%t )$o&$ams to&ethe$ i% i%te&$ated s"stem a)ab!e o# $es)o%di%& to dis)utes at di##e$e%t !e(e!s

I%stitutio%a! !ea$%i%& a%d im)$o(ed s"stem #o$ )atie%t a$e as $esu!t o# $oot ause a%a!"sis Re)ai$ G $etai% $e!atio%shi)s Patie%ts satis#ied 'ith

$es)o%se

be%e#its a%%ot be measu$ed

A@

#ISCUSSIO!

This se tio% dis usses the #i%di%&s o# both the !ite$atu$e $e(ie' a%d o# the i%te$(ie's- It is di(ided i%to the #o!!o'i%& sub6se tio%s:

1. Mai% D"%ami s i% Hea!th a$e Co%#!i t 2. De#i%itio%s o# Su ess 3. Theo$eti a! Shi#t To'a$ds Re!atio%a! Mode! 4. Ea$!" I%te$(e%tio%: Hea!th Ca$e .o$4e$s as the F$o%t Li%e 5. Edu atio% a%d T$ai%i%&: O))o$tu%ities to C$eate Positi(e Cha%&e 6. Me$&i%& the Cu!tu$es o# Hea!th Ca$e a%d Dis)ute Reso!utio% 7. Su&&ested Futu$e Resea$ h

1. Main #(namics in Healt&care Conflict

The t'o d"%ami s #ou%d most )$omi%e%t!" i% both the !ite$atu$e a%d the i%te$(ie' data 'e$e )atie%t6)$o(ide$ dis)utes a%d )$o(ide$6)$o(ide$ dis)utes- Hea!th a$e )$o(ide$s te%ded to asso iate o%#!i t mo$e !ose!" 'ith )$o(ide$6)$o(ide$ o%#!i ts a%d ommu%i atio%6based )atie%t6)$o(ide$ o%#!i t- This 'as i% o%t$ast to ma%" #u!!6 time o%#!i t ma%a&eme%t )$o#essio%a!s, es)e ia!!" thou&h %ot e8 !usi(e!" those 'ith !e&a! ba 4&$ou%ds, 'ho #o used mu h mo$e o% ad(e$se out ome i%te$(e%tio%s, dis !osu$e o%(e$satio%s, a%d ma!)$a ti e !aims- Some i%te$(ie'ees me%tio%ed o%#!i ts 'ith )atie%ts9 #ami!ies, es)e ia!!" i% the o%te8t o# e%d6o#6!i#e de isio%s a%d bioethi s ommittees, a!thou&h this d"%ami 'as %ot )$omi%e%t i% eithe$ the !ite$atu$e o$ the i%te$(ie's- A mu h sma!!e$ %umbe$ o# )h"si ia% e8e uti(es a%d o%#!i t ma%a&eme%t s)e ia!ists hi&h!i&hted )$o(ide$6admi%ist$atio% o%#!i t a%d dis$u)ti(e beha(io$-

I%te$(ie's 'ith hea!th a$e )$o(ide$s #o used o% ommu%i atio%7 i%deed, this 'as the B&o6toC 'o$d i% the i%te$(ie's 'ith most hea!th a$e )$o(ide$s- I% ma%" i%te$(ie's, )$o(ide$s used the te$m B)oo$

AA

ommu%i atio%C s"%o%"mous!" 'ith o%#!i t, i%di ati%& the e8te%t to 'hi h the %eed #o$ &ood ommu%i atio% has be ome i%&$ai%ed i% hea!th a$e u!tu$es- Nume$ous )$o(ide$s %oted bei%& t$ai%ed i% s hoo! a%d $eside% " o% the im)o$ta% e o# &ood ommu%i atio% i% $e!atio%s 'ith )atie%ts, thou&h the )$ima$" o%te8t i% 'hi h the" $e)o$ted most %eedi%& those s4i!!s 'as 'ith othe$ )$o(ide$s- The %eed #o$ o!!abo$ati(e 'o$4i%& $e!atio%shi)s 'ith othe$ )$o(ide$s 'as the si%&!e most $e#e$e% ed o%#!i t o%te8t b" hea!th a$e )$o(ide$s i% the !ite$atu$e a%d the i%te$(ie's- This su))o$ts the su&&estio% that ommu%i atio% t$ai%i%&s ma" be a% e##e ti(e a ess )oi%t #o$ i%t$odu i%& o%#!i t ma%a&eme%t to hea!th a$e )$o#essio%a!s-

.ith some e8 e)tio%s, the !ite$atu$e a%d i%te$(ie's #$om ADR )$o#essio%a!s as a 'ho!e 'e$e mo$e !i4e!" to #o us o% )atie%t6)$o(ide$ dis)utes, s)e i#i a!!" those $e!ated to u%a%ti i)ated out omes a%d !iti&atio%- .hi!e some o# this ma" be att$ibutab!e to the !e&a! ba 4&$ou%ds o# ma%" #u!!6time ADR )$o#essio%a!s, a se o%d #a to$ ma" be that the$e has t$aditio%a!!" bee% mo$e mo%e" at sta4e i% this d"%ami - The hi&he$ #i%a% ia! $is4 o# these o%#!i ts seems to ha(e )!a"ed a $o!e i% &i(i%& these o%#!i ts mo$e atte%tio%, i% tu$% i% $easi%& the !i4e!ihood that ADR a%d o%#!i t ma%a&eme%t i%te$(e%tio%s to dea! 'ith them 'i!! be $e*uested, #u%ded, a%d '$itte% about- Ma%" o# the o%#!i t ma%a&eme%t s"stems dis ussed i% the !ite$atu$e 'e$e de(e!o)ed i% $es)o%se to )atie%t6)$o(ide$ dis)utes, a!thou&h this #o us ma" shi#t 'ith the %e' /oi%t Commissio% sta%da$ds o% ma%a&i%& 'o$4)!a e o%#!i t-

Nume$ous i%te$(ie'ees !a$&e!" $e#e$$ed to o%e o%#!i t d"%ami a!o%e, at times i%di ati%& a% e8)!i it !a 4 o# a'a$e%ess o# othe$ d"%ami s- .hi!e tu%%e! (isio% 'as !ess )$ese%t i% the !ite$atu$e, mu h o# the !ite$atu$e a%d i%te$(ie' data su&&ested that e$tai% t")es o# o%#!i ts Eo#te% )$o(ide$6)$o(ide$F a$e dea!t 'ith b" a!te$%ati(e s"stems Eo#te% HRF that a$e %ot 'e!! oo$di%ated 'ith o%#!i t ma%a&eme%t )$o&$ams i% the o$&a%i5atio% 'o$4i%& o% othe$ d"%ami s-

.hi!e mu h o# the !ite$atu$e $e#e$$ed to mo$e #o$ma!, !ate$ sta&e i%te$(e%tio%s, hea!th a$e )$o(ide$s 'e$e mo$e !i4e!" to dis uss i%#o$ma!, ea$!" i%te$(e%tio%s $es)o%si(e to $e!atio%shi)s, t$ust, a%d time o%st$ai%ts-

A?

The !ite$atu$e su$(e" a!so %oted si&%i#i a%t di##e$e% es i% the o$ie%tatio% o# t")i a! o%#!i t ma%a&eme%t $es)o%ses to )$o(ide$6)$o(ide$, )$o(ide$>admi%ist$ato$, a%d )atie%t6)$o(ide$ dis)utes, as the #o!!o'i%& tab!e sho's: Tab!e ;- Co%#!i t Ma%a&eme%t Fo i %ynamic P$o(ide$6P$o(ide$ P$o(ide$6 Admi%ist$atio% Patie%t6Pa"e$ Patie%t6P$o(ide$: Ge%e$a! Ad(e$se e(e%t dis !osu$e Sha$ed de isio% ma4i%& Ethi s o%#!i t S!illAbuilding 7ocus Co!!abo$atio%, team bui!di%&, o%#!i t a%a!"sis, i%te$est6based %e&otiatio%, ommu%i atio% Pa$ti i)ato$" de isio% ma4i%&, o%se%sus bui!di%&, i%te$est6based %e&otiatio% Ne&otiatio% Commu%i atio% Di##i u!t o%(e$satio%s, i%te$est6based mediatio%, t$a%s#o$mati(e mediatio% Et$e%dF Pa$ti i)ato$" de isio% ma4i%&, ommu%i atio%, o%#!i t a%a!"sis, mediatio% )$o ess s4i!!s Co%#!i t a%a!"sis, ommu%i atio%, mediatio% )$o ess, i%te$est6based %e&otiatio% 'ntervention Model Coa hi%&

Fa i!itatio% Ad(o a ", mediatio% T$ai%i%& Mediatio%, oa hi%& T$ai%i%&, oa hi%& E#o$ )atie%tF T$ai%i%&, mediatio%

U%de$sta%di%& the di##e$e%t o%#!i t d"%ami s a%d the o%#!i t ma%a&eme%t i%te$(e%tio%s asso iated 'ith ea h a% im)$o(e the o%#!i t ma%a&eme%t s"stems a%d t$ai%i%&s bei%& desi&%ed #o$ hos)ita!s i% the 'a4e o# the /oi%t Commissio% sta%da$ds- Si% e a maDo$ ha!!e%&e #o$ )$odu ti(e o%#!i t e%&a&eme%t is $e o&%i5i%& that the o%#!i t e(e% e8ists, i&%o$i%& Eo$ #ai!i%& to hi&h!i&htF some o# the d"%ami s i%(o!(ed 'ith hea!th a$e dis)utes is u%he!)#u! a%d ma4es mai%st$eami%& om)$ehe%si(e, )$odu ti(e e%&a&eme%t 'ith o%#!i t mo$e di##i u!tA 4%o'!ed&i%& 'hat o%#!i t d"%ami s a$e i% !uded a%d e8 !uded #$om e8isti%& o%#!i t ma%a&eme%t s"stems a% he!) hea!th a$e )$o(ide$s a%d )$o&$ams ada)t as %e essa$"-

2. #efinitions of Success
?3

This $esea$ h 'as u%su ess#u! i% a

essi%& the i%te$%a! do ume%ts o# a tua! hea!th a$e o%#!i t

ma%a&eme%t )$o&$ams, thus it 'as %ot )ossib!e to om)a$e the )e$#o$ma% e i%di ato$s a%d mat$i es that )a$ti u!a$ o%#!i t ma%a&eme%t )$o&$ams use to measu$e the e##e ti(e%ess o# thei$ a ti(ities- .hi!e a )$o(ed u%su essi%& su h data 'as attem)ted i% the ea$!" )hases o# the $esea$ h )$o ess, it

ess#u! a%d !a$&e!" u%$ea!isti &i(e% the o%te8t o# the $esea$ h-

I%stead, the !ite$atu$e a%d i%te$(ie's se$(ed as the so!e sou$ e #o$ e8)!o$i%& de#i%itio%s o# su ess- Re!ati(e!" !itt!e !ite$atu$e 'as #ou%d that s"stemati a!!" dis ussed de#i%itio%s o# su ess o$ )e$#o$ma% e i%di ato$s )e$tai%i%& to the di##e$e%t d"%ami s o# hea!th a$e- Simi!a$ ha!!e%&es 'e$e %oted 'ith the i%te$(ie's-

Des)ite this !a 4 o# !a$it" o% ho' most o%#!i t ma%a&eme%t )$o&$ams a tua!!" de#i%e a%d measu$e su ess, the !ite$atu$e $e(ie' a%d i%te$(ie' data did su&&est that de#i%itio%s o# su ess#u! o%#!i t ma%a&eme%t (a$" si&%i#i a%t!" a $oss hea!th a$e o%#!i t d"%ami s- .ithi% d"%ami s, the$e is &e%e$a! o%siste% " i% o(e$a$ hi%& &oa!s a%d b$oad de#i%itio%s o# su a!thou&h di##e$e% es eme$&e e(e% he$e i% $es)o%se to (a$iatio% i% !o a! o%te8tess,

The i%te$(ie's a%d !ite$atu$e $e(ie's )$odu ed these $es)o%ses $e&a$di%& i%di ato$s o# su #o$ o%#!i t ma%a&eme%t:

ess

?0

Tab!e =- I%di ato$s o# Su ess #o$ Co%#!i t Ma%a&eme%t

P$o(ide$ 6 P$o(ide$ Pt- > P$o(ide$: Ge%e$a! Im)$o(ed )atie%t satis#a tio% Pt- > P$o(ide$: SDM Patie%ts $e ei(e t$eatme%t the" )$e#e$ Patie%ts ha(e $ea!isti e8)e tatio %s #o$ out omes Patie%t is em)o'e$e d i% $e!atio%shi ) I% $eased e##i ie% " A(oided u%%e essa $" t$eatme%ts Reso!utio% o# issue a hie(ed Pt-6 P$o(ide$: Ad(e$se Out omes Ethi a! dut" #u!#i!!ed Pt-6 P$o(ide$: Ethi s Dis)utes Ho%o$ed )atie%t9s 'ishes P$o(ide$ > Admi% Im)$o(ed $e!atio%s 'ith )h"si ia%s Patie%t 6 Pa"e$ T$a%sa tio % sett!ed

A hie(ed ea$!" )hase, !o'6 dis$u)tio%, i%te$%a! $eso!utio% Ea(oid i%(o!(i%& HR G ma%a&eme%tF Im)$o(ed sta## mo$a!e, !ess #$ust$atio%

Im)$o(ed ommu%i atio%

Im)$o(ed )atie%t t$ust

Im)$o(ed de isio% ma4i%& )$o ess P$odu ti(e use o# o%#!i t

Patie%t satis#a tio % 'ith $eso!utio% C!ie%ts $etai%ed

Im)$o(ed o!!abo$atio% amo%&st hea!th a$e )$o(ide$s I% $eased e##i ie% " i% 'o$4)!a e I% $eased bu" i% to the de isio% ma4i%& )$o ess, t$eatme%t $e&ime%, o(e$a!! a$e &oa!s Fe'e$ em)!o"ee &$ie(a% es to HR G$eate$ sta## $ete%tio% Fe'e$ $e)o$ts o# dis$u)ti(e beha(io$ Fe'e$ medi a! e$$o$ $oot ause a%a!"ses )oi%t to )$o(ide$ ommu%i atio% b$ea4do'% as ause Sta## #ee! mo$e om#o$tab!e )a$ti i)ati%& a%d

Im)$o(ed )atie%t t$ust

Im)$o(ed )atie%t sa#et" out omes Fe'e$ !a'suits Faste$ $eso!utio%

Fami!" om#o$tab!e 'ith out ome

Mai%tai% G $esto$e $e!atio%shi)s P$ote t )$o#essio%a! $e)utatio% G )ositi(e )ub!i )e$ e)tio% o# i%dust$"

Fe'e$ #o$ma! om)!ai%ts #i!ed Fe'e$ !a'suits Im)$o(ed )atie%t sa#et" out omes

Lo'e$ o(e$a!! !e&a! e8)e%ses Less )$o(ide$ st$ess Mai%tai% $e!atio%shi ) Lea$% #$om e$$o$s

s)ea4i%& out at 'o$4

O%e o# the )$ob!ems hi&h!i&hted b" i%te$(ie'ees is the di##i u!t" i% *ua%titati(e!" a)tu$i%& some o# the most im)o$ta%t im)a ts o# o%#!i t ma%a&eme%t- The" su&&ested that ma%" o# the most im)o$ta%t de#i%itio%s o# su ess#u! o%#!i t ma%a&eme%t a$e ha$d to measu$e, es)e ia!!" i% the o%te8t o# )$o(ide$6)$o(ide$ o%#!i tsSu&&ested e8am)!es o# the t")es o# ha%&es that i%di ate dee)e$ !e(e!s o# su ess i% !ude: the 'o$4)!a e is !ess st$ess#u!7 $e!atio%shi)s ha(e bee% im)$o(ed7 sta## a$e mo$e e%&a&ed i% 'o$4

?2

a%d 'i!!i%& to )a$ti i)ate i% de isio% ma4i%&7 a%d &$eate$ a'a$e%ess a%d a 4%o'!ed&eme%t o# othe$s9 %eeds-

The !esso% d$a'% #$om this di(e$sit" o# de#i%itio%s o# su

ess i% hea!th a$e is that it ma" %e(e$ be ess a $oss di##e$e%t o%#!i t

)ossib!e to sta%da$di5e o%#!i t ma%a&eme%t &oa!s a%d de#i%itio%s o# su

d"%ami s a%d o%te8ts- The im)!i atio% #o$ t$ai%i%&s, i%te$(e%tio%s, a%d o%#!i t ma%a&eme%t s"stems is that it is $u ia!!" im)o$ta%t to o%du t a $obust o%#!i t a%a!"sis a%d %eeds assessme%t as )a$t o# the desi&% )hase so as to ide%ti#" the most a))$o)$iate i%di ato$s o# su ess #o$ that )a$ti u!a$ o%te8t-

I%di ato$s t$a 4i%& )atie%t satis#a tio%, )atie%t sa#et", *ua!it" o# a$e, ost e##e ti(e%ess, e##i ie% ", sta## satis#a tio%, a%d sta## $ete%tio% 'i!! i% $easi%&!" be ome the ommo% be% hma$4s a&ai%st 'hi h o%#!i t ma%a&eme%t s"stems a$e e(a!uated- Ho'e(e$, e8)a%di%& a%d mai%tai%i%& su))o$t #o$ hea!th a$e o%#!i t ma%a&eme%t s"stems, t$ai%i%&s, a%d i%te$(e%tio%s $e*ui$es a )e$suasi(e e o%omi a$&ume%t- Re&a$d!ess o# the ethi a! o$ u!tu$a! a$&ume%ts su))o$ti%& it, 'ithout a sustai%ab!e busi%ess Dusti#i atio% at its o$e, o%#!i t ma%a&eme%t 'i!! #o$e(e$ $emai% (u!%e$ab!e i% $esou$ e6 o%st$ai%ed hea!th a$e e%(i$o%me%ts- Fo$ this $easo%, de#i%itio%s o# su ess a%d )e$#o$ma% e met$i s, 'hethe$ made e8)!i it o$ %ot, 'i!! be i%de!ib!" !i%4ed 'ith #i%a% ia! im)a ts-

3. T&eoretical S&ift To3ards "elational Model

The i%te$(ie's hi&h!i&hted the $e e%t theo$eti a! shi#t a'a" #$om the t$aditio%a! i%te$est6based %e&otiatio% mode! to'a$ds $e!atio%a! mode!s o# o%#!i t $eso!utio%- I%te$(ie'ees su&&ested that the eme$&i%& $e!atio%a! mode!s mo(e a'a" #$om %e&otiated so!utio%s #o$ a bou%ded o%#!i t e(e%t a%d shi#t the #o us to'a$ds o%&oi%&, $e!atio%shi)6 based o% e)ts su h as t$ust, $es)e t, $e o&%itio%, a%d $e)utatio%-

?;

The

e%t$a! $o!e o# $e!atio%shi)s su&&ests that &e%ui%e!" e%&a&i%& 'ith

o%#!i ts i% hea!th a$e $e*ui$es

e%ab!i%& dee)e$

o%(e$satio%s o% )o'e$, de isio% ma4i%&, $es)e t, autho$it", ide%tit", a%d )e$ e)tio%,

themes !a$&e!" outside the s o)e o# i%te$est6based %e&otiatio% mode!s- A))$oa hes eme$&i%& #$om the t$a%s#o$mati(e mediatio% mode!s ma" he$a!d #o$th omi%& t$e%ds i% the #ie!d-

O%e i%te$(ie'ee su&&ested that de#i%itio%s o# su

ess )oi%ti%& to $e o&%itio% Ea 4%o'!ed&eme%t

o# 'hat hea!th a$e )$o(ide$s do a%d o# thei$ huma% !imitatio%sF, to $es)e t Ethe desi$e be $es)e ted i% thei$ 'o$4)!a e a%d #o$ thei$ 'o$4F, a%d to ho%o$ab!" se$(i%& )atie%ts E !i%i a! out ome a%d )atie%t satis#a tio%F he$a!d the ha%&e o# #o us that ma" eme$&e 'ith $e!atio%shi)6 based mode!s o# o%#!i t $eso!utio%- The e8te%t to 'hi h su h de#i%itio%s o# su ess 'i!! su))!a%t

o$ sim)!" e8)a%d u)o% u$$e%t e8)e tatio%s #o$ o%#!i t ma%a&eme%t $emai%s to be see%-

Resea$ h a%d theo$eti a! $e#!e tio% is $e*ui$ed o% 'hat it mea%s to ste) be"o%d a% i%te$est6 based %e&otiatio% mode! to'a$ds $e!atio%a! mode!s o# o%#!i t e%&a&eme%t- .hat a$e the im)!i atio%s o# thisI Ho' does this di##e$e% e i% #$ame'o$4 ma%i#est i% )$a ti eI Does this om)!ete!" $e6 o% e)tua!i5e the &oa! #o$ a o%#!i t i%te$(e%tio%I Ho' a% the %eed #o$ dee)e$ o%(e$satio%s be i%te&$ated i%to hea!th a$e setti%&s 'ith se(e$e time o%st$ai%tsI Theo$eti a! a%d e(a!uati(e $esea$ h is $e*ui$ed to #u$the$ o% e)tua!i5e this eme$&i%& t$e%d-

4. Earl( Inter1ention: Healt& Care %or<ers as t&e ront Line

Medi a! sta## 'i!! i% $easi%&!" )!a" a !eadi%& $o!e i% hea!th a$e o%#!i t $eso!utio% as mo$e o# the #o us shi#ts to )$e(e%tio%, ea$!" $e o&%itio% a%d ea$!" i%te$(e%tio% i% o%#!i ts- C!i%i ia%s, %ot ADR )$o#essio%a!s, a$e the (a%&ua$d #o$ the ea$!iest i%te$(e%tio%s- Di$e t ma%a&eme%t o# o%#!i t 'i!! i% $easi%&!" $est 'ith the &$o'i%& ad$es o# hea!th a$e 'o$4e$s t$ai%ed a%d em)o'e$ed to )$odu ti(e!" e%&a&e 'ith the o%#!i ts the" 'it%ess dai!"-

?=

Mu h o# 'hat is '$itte% about ADR i% hea!th a$e i%(o!(es !ate$ sta&e i%te$(e%tio%s- Dis !osu$e a% be a% e8 e)tio% to this, i% that it a% be !au% hed immediate!" a#te$ dis o(e$i%& a% e$$o$- Ma%" i%te$(e%tio%s a$e o%!" a ti(ated o% e a #o$ma! om)!ai%t has bee% made- Fu$the$, mu h o# the !ite$atu$e, es)e ia!!" that eme$&i%& #$om the hea!th !a' #ie!d, o%ti%ues to #$ame ea$!" i%te$(e%tio% as mo$e *ui 4!" mobi!i5i%& e8te$%a! ADR )$o#essio%a!s to $es)o%d to dis)utes at ea$!ie$ sta&es- These a$e o%side$ab!" di##e$e%t o% e)tio%s o# 'ho is u!timate!" $es)o%sib!e #o$ e%&a&i%& 'ith the o%#!i t-

The utti%& ed&e i% ea$!" i%te$(e%tio% o%#!i t ma%a&eme%t !ies %ot i% a ti(ati%& a% outside %eut$a! *ui 4!" but i% i% $easi%& the a)a it" a%d 'i!!i%&%ess o# )a$ties di$e t!" i%(o!(ed 'ith the o%#!i t to $edi$e t the disa&$eeme%t i% a )ositi(e 'a" as it is eme$&i%&- This $e#o uses the i%te$(e%tio% a'a" #$om a% ADR )$o#essio%a! to'a$ds bette$ e*ui))i%& !i%i ia%s a%d hea!th a$e sta## to dea! 'ith dis)utes- A 4%o'!ed&i%& this $e)$ese%ts a shi#t i% o%t$o! o# the hea!th a$e ADR #ie!d-

Fu$the$i%& this shi#t i% i%#!ue% e, the thi$d )a$t" a!!ed o% to mediate o$ )$o(ide o%#!i t oa hi%& 'i!! i% $easi%&!" be a su)e$(iso$ o$ o'o$4e$ $athe$ tha% a% i%te$%a! o$ e8te$%a! %eut$a!- The %eed #o$ ADR )$o#essio%a!s 'i!! %ot disa))ea$, but thei$ $o!es ma" &$a(itate to'a$ds me%to$ a%d maste$ t$ai%e$, e%ab!i%& othe$s to e%&a&e di$e t!"- Es)e ia!!" du$i%& the t$a%sitio% "ea$s, outside ADR )$o#essio%a!s 'i!! sti!! be $e*ui$ed to )e$#o$m im)o$ta%t $o!es i% i%te&$ated o%#!i t e%&a&eme%t s"stems, 'o$4i%& as mediato$s, ombuds, #a i!itato$s, o%#!i t oa hes, a%d t$ai%e$sCom)$ehe%si(e s"stems that uti!i5e tie$ed $es)o%ses to o%#!i ts, se!e ti(e!" a ti(ate o%#!i t e%&a&eme%t s)e ia!ists, a%d i%te%tio%a!!" de(e!o) ad(a% ed s4i!!s i% o%#!i t6 om)ete%t !eade$s #o$m a st$o%& ba 4sto) #o$ hea!th a$e )$o(ide$s e%&a&i%& 'ith o%#!i t o% the #$o%t6!i%es-

Fi%a!!", the Liaiso% Ph"si ia% Mode! 'as o%e o# the mo$e i%te$esti%& a))$oa hes that ou!d be ada)ted #o$ a (a$iet" o# o%te8ts to im)$o(e ommu%i atio% a%d o!!abo$atio% i% a!! hea!th a$e $e!atio%shi)s- .ith

?1

$e!ati(e!" !itt!e i%(estme%t o# a)ita! o$ time, this mode! o)e%s ha%%e!s #o$ o%sta%t, o%&oi%& dia!o&ue that is %o%6 o%#$o%tatio%a!- Resista% e to ha%&e is mi%imi5ed as the a))$oa h uti!i5es st$u tu$es a%d s"stems that ma%" )$o(ide$s a$e a!$ead" #ami!ia$ 'ith- To ma4e )a$ti i)atio% i% a !iaiso% )h"si ia% mode! att$a ti(e to bus" )$a titio%e$s, the )$o&$am eithe$ %eeds to be #u%ded o$ e!eb$ated- C!i%i ia% !eade$s 'ho 'a%t to ad(a% e i% thei$ o%#!i t ma%a&eme%t s4i!!s %eed to be ide%ti#ied, &$oomed, a%d su))o$ted- I% $etu$%, the !iaiso% )h"si ia% mode! )$o(ides $e&u!a$ o))o$tu%ities to )$a ti e a%d mode! o%#!i t ma%a&eme%t s4i!!s, he!)i%& !e(e$a&e ha%&e i% ho' that 'o$4)!a e u!tu$e e%&a&es 'ith o%#!i t-

5. Education and Training: Opportunities to Create 0ositi1e C&ange

Edu atio% a%d t$ai%i%& 'e$e ide%ti#ied th$ou&hout the !ite$atu$e a%d i%te$(ie's as $u ia! #o$ $eati%& o%#!i t6 om)ete%t hea!th a$e u!tu$es- This se tio% out!i%es te% 4e" #i%di%&s $e!ated to o%#!i t ma%a&eme%t t$ai%i%& a%d edu atio%-

*pportunities for Training: The i%te$(ie's a%d !ite$atu$e ombi%ed to )$odu e a b$oad )i tu$e o# o))o$tu%ities #o$ t$ai%i%&- The #o!!o'i%& tab!e !ists a summa$" o# )ossib!e t$ai%i%& (e%ues:

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Tab!e 1: Le%ues #o$ Co%#!i t Ma%a&eme%t T$ai%i%&s i% Hea!th a$e

Training *pportunity) Nu$si%& S hoo! Ad(a% ed P$a ti e %u$si%&G %u$si%& ma%a&eme%t &$aduate s hoo! )$o&$ams Medi a! S hoo! Ph"si ia% Reside% " Comments +asi o%#!i t ma%a&eme%t t$ai%i%&s as )a$t o# ommu%i atio% ou$ses T$ai%i%&s e8ist i% )$o&$ams #o$ Ad(a% ed P$a ti e %u$ses a%d %u$se admi%ist$ato$ ou$ses Some )$o&$ams EC$ei&hto% U%i(e$sit" Do to$ate i% Nu$si%& De&$eeF $e*ui$e %u$si%& stude%ts to ta4e 26; &$aduate ou$ses #$om o%#!i t $eso!utio% de)a$tme%t Re e)ti(e audie% e as %u$se ma%a&e$s e8)e ted to %e&otiate a%d dea! 'ith si&%i#i a%t o%#!i t o% dai!" basis Medi a! s hoo!s usua!!" #it o%#!i t ma%a&eme%t6$e!ated t$ai%i%& i% 'ith the ommu%i atio% s4i!!s se tio%, so the" do%9t %e essa$i!" !abe! it as o%#!i t $eso!utio% 0-1 hou$ modu!es o% sha$ed de isio% ma4i%& )i!oted at Da$tmouth Medi a! S hoo! i% ommu%i atio%s se tio% U%i(e$sit" o# Mi hi&a% has estab!ished CR modu!es #o$ medi a! s hoo! He!)s that ommu%i atio% t$ai%i%& is %o' ma%dated b" boa$ds a%d medi a! edu atio% u$$i u!umTuse this as a ess )oi%t Commu%i atio% ou$ses ma" sti!! %ot ha(e as mu h 'ei&ht as ha$d6s ie% e ou$ses, so ha!!e%&es $emai% to &etti%& mo$e time #o$ tea hi%& ommu%i atio% i% med s hoo! u$$i u!um He!)s that ommu%i atio% t$ai%i%& is %o' ma%dated b" boa$ds a%d medi a! edu atio% u$$i u!umTuse this as a ess )oi%t 036da" 'i%do' be#o$e sta$t o# $eside% ", 'ith a)ti(e audie% e 'ho is $e e)ti(e to a!! ad(i e but sti!! be#o$e time )$essu$es sta$t Reside%ts i% some )$o&$ams a$e e8)osed to sha$ed de isio% ma4i%& as )a$t o# $eside% " Need CME a%d CE $edit #o$ ou$ses to ma4e it (iab!e Ede!stei%Te8)a%d to 'ee4e%ds, mu!ti)!e da" ou$ses, et I%6house sta## t$ai%i%&s E#o$ s)e i#i u%it o# hos)ita!, et F o%e o)tio% O##e$ di##e$e%t modu!es o# di##e$e%t !e%&ths a%d !e(e!s o# ad(a% eme%t Ca% o##e$ Doi%t t$ai%i%& 'ith hea!th a$e )$o(ide$s a%d e8e uti(es o% hea!th a$e ADR, es)- dis !osu$e a%d ma!)$a ti e T$ai%i%& modu!es o% #a i!itatio%, )a$ti i)ato$" de isio% ma4i%&, o%se%sus bui!di%& Uti!i5e ase studies o% e##e ti(e )h"si ia%6admi%ist$atio% e%&a&eme%t Ca% do Doi%t t$ai%i%&s 'ith hea!th )$o#essio%a!s Tea h o!de$ t$ai%e$s Esu h as )h"si ia%s 'o$4i%& i% tea hi%& setti%&sF 'ho a$e $e e)ti(e to the im)o$ta% e o# ommu%i atio% a%d )$o ess s4i!!s7 the" 'i!! the% tea h %e'e$ medi a! $eside%ts7 the se!!i%& )oi%t is that )assi%& o% these im)o$ta%t )$o ess s4i!!s is B)a$t o# thei$ !e&a "C .o$4 th$ou&h )eo)!e 'ho ha(e bee% so ia!i5ed to (a!ue huma% $e!atio%shi)s a%d ommu%i atio%7 this mea%s a u!tu$ati%& )eo)!e to (a!ue *ua!it" o# a$e E%ot Dust !i%i a! out omesF a%d the i%te$)e$so%a! d"%ami Estab!ish G su))o$t ommu%ities o# )$a ti e Co%side$ ado)ti%& the te$m B o6me%to$i%&C to $edu e se%siti(ities to hie$a$ h"O))o$tu%it" to $eate o%#!i t ma%a&eme%t !eade$s 'ho 'i!! mode! &ood beha(io$ Co%du i(e to tie$ed t$ai%i%& Re!iab!e #o$um #o$ t$ai%i%&, $e#!e tio% o% o%#!i t, a%d sha$i%&

Co%ti%ui%& Edu atio%

La' S hoo! Hea!th Admi%ist$atio% &$aduate edu atio%

Me%to$shi) G Mode!i%&

+ioethi s Committees

HR Ne' Em)!o"ee O$ie%tatio% T$ai%i%&s

Limitatio%: t")i a!!" !o' (o!ume o# ases )e$ "ea$ Fami!ia$i5e a!! %e' em)!o"ees 'ith o%#!i t ma%a&eme%t s"stems as )a$t o# o$ie%tatio% t$ai%i%& Cou!d o##e$ basi CM ommu%i atio% t$ai%i%& as )a$t o# o$ie%tatio% Use HR t$ai%i%&s to i% $ease a'a$e%ess about CM s"stems, o))o$tu%ities #o$ me%to$i%&Gad(i e, oa hi%& o))o$tu%ities, et -

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Training *pportunity) I%stitutio%a! Cha%&e I%itiati(es E8e uti(e Coa hi%& E o%#!i t om)ete% " #o$ e8e uti(es a%d se%io$ !eade$shi)F G$a%d Rou%ds Patie%t Sa#et" I%itiati(es

Comments Cha%&e )$o esses te%d to $eate o%#!i t T")i a!!" #u%di%& e8ists #o$ t$ai%i%& as )a$t o# i%itiati(es P$o(ides o%te8t to a))!" s4i!!s !ea$%ed i% t$ai%i%& T$ai%i%&s a% be tai!o$ed to s)e i#i o%te8t Fo$ )eo)!e e!e(ated to )ositio%s o# i% $easi%& autho$it" a%d ma%a&eme%t, ma%" #ee! !i4e the" a$e as4ed to do thi%&s #o$ 'hi h the" ha(e %o t$ai%i%& G$oom #o$ !eade$shi) )ositio%s EMa5u$ said somethi%& simi!a$ about this i% i%te$(ie'F Leade$shi) o#te% )u$ hase t$ai%i%&s #o$ sta## but do%9t 4%o' o$ )$a ti e the s4i!!s themse!(es Leade$shi) !e(e! is im)o$ta%t be ause i# the" do%9t ha%&e, the% those !o'e$ a%9t im)!eme%t thei$ s4i!!s T$ai%i%& )a$amete$s Etime, to)i F ma" be mo$e o%st$ai%ed E8isti%& #o$um 'ith !e&itima " Im)o$ta%t o))o$tu%it" to use o%#!i t ma%a&eme%t s4i!!s 'he% ma%a&i%& )$o esses o# ha%&e Ca% !i%4 'ith t$ai%i%& Pote%tia! Dusti#i atio% o# timeGmo%e" #o$ i%t$odu i%& t$ai%i%& O(e$a$ hi%& im)a t o% o$&a%i5atio% Ma%dato$" so a%%ot be i&%o$ed i%de#i%ite!" Su))o$ts mai%st$eami%& o%#!i t ma%a&eme%t a%d i%te&$ati%& 'ith b$oade$ o$&a%i5atio%a! (a!ues7 a% mo$e !ose!" $e!ate t$ai%i%& to e8isti%& o%#!i ts i% team T$ai%i%& audie% e a% #o us o% u%its Ei-e- mu!tidis i)!i%a$" 'o$4 teams i% ICUF #o$ mo$e ta$&eted im)a t 'ith )ote%tia! #o$ !o%&e$6te$m e%&a&eme%t a%d $ei%#o$ eme%t o# !ea$%i%& E##e ti(e 'a" to o(e$ ome si!os a%d bui!d o!!abo$atio% Ma" he!) #o$m ommu%ities o# )$a ti e

Ma%a&eme%t G Leade$shi) T$ai%i%& #o$ hea!th a$e )$o(ide$s

/oi%t Commissio% A $editatio% e##o$ts Team bui!di%& a%d team t$ai%i%& e8e$ ises

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Ma%" o# these su))!eme%ts a%d a!te$%ati(es to #o$ma! 'o$4sho)s o% o%#!i t ma%a&eme%t )$o(ide ost6 a%d time6e##i ie%t t$ai%i%& #o$ums 'ith e8isti%& !e&itima "- Rotati%& th$ou&h (a$ious #o$ums #o$ t$ai%i%& at sho$te$ i%te$(a!s a% he!) $ei%#o$ e the !ea$%i%& #$om ea$!ie$ t$ai%i%&s, $eate im)o$ta%t o))o$tu%ities #o$ me%to$i%& a%d mode!i%&, a%d #o$m the basis #o$ ommu%ities o# )$a ti e-

Partnered Training- Mi8ed t$ai%e$ teams o%sisti%& o# a !i%i ia% 'ith some ADR s4i!!s a!o%&side a %o%6 !i%i ia% ADR )$o#essio%a! a% be a% e##e ti(e 'a" #o$ outside t$ai%e$s to bui!d !e&itima " 'ith s4e)ti a! )$o(ide$s- This is a% o))o$tu%it" to bui!d i%6house a)a it" 'he% these )a$t%e$ed t$ai%i%&s a$e %ested 'ithi% a b$oade$ t$ai%i%&6o#6t$ai%e$s )$o&$am #o$ the o$&a%i5atio%- T$ai%e$s must be ab!e to s)ea4 'ith autho$it" a%d u%de$sta%di%& o# the issues, a%d be ab!e to a%s'e$ *uestio%s the )a$ti i)a%ts b$i%& u)- Li%4i%& a !i%i ia% E'ho ma" !a 4 de)th i% o%#!i t ma%a&eme%t but u%de$sta%ds the !i%i a! o%te8tF a%d a% ADR )$o#essio%a! E'ho has ad(a% ed o%#!i t ma%a&eme%t 4%o'!ed&e but !a 4s autho$it" o% the !i%i a! o%te8tF a% om)!eme%t s4i!!s %i e!"-

'n healthcare- time is shortY T$ai%i%&s must be *ui 4 a%d )ass o% te h%i*ues a%d s4i!!s that !et )eo)!e &et to the dee)e$ issues #ast- Fo$ i%te$est, $ete%tio%, a%d !e&itima ", t$ai%i%&s must be ha%ds6o% 'ith #eedba 4-

7ollow up+ O))o$tu%ities #o$ #o!!o'6u) t$ai%i%& a%d su))o$t a$e %e essa$"- O%e6o## t$ai%i%&s a$e i%su##i ie%t, as o%#!i t ma%a&eme%t t$ai%i%&s 'o%9t sti 4 'ithout !o%&e$6te$m $ei%#o$ eme%t- Loo4 to i%te%tio%a!!" estab!ish me%to$shi) G mode!i%& $e!atio%shi)s Ea%a!o&ous to $eside%tGatte%di%& d"%ami F a%d ommu%ities o# )$a ti e, !i%4i%& these 'ith t$ai%i%&s- T$" to o%%e t t$ai%i%&s to b$oade$ o%#!i ts o$ issues the o$&a%i5atio% is #a i%&, i% o$de$ to !i%4 the t$ai%i%& di$e t!" 'ith )$a ti e o))o$tu%ities-

Mentoring and modeling- C$eati%& o))o$tu%ities #o$ $e&u!a$ me%to$i%& a%d mode!i%& o# &ood o%#!i t e%&a&eme%t beha(io$ is $u ia! #o$ !o%&6te$m ha%&e- T$ai%i%&s shou!d be imbedded 'ith mo$e s"stemati o))o$tu%ities #o$ )$a ti e a%d $e#!e tio%- Uti!i5i%& t$ai%i%& o# t$ai%e$ mode!s a%d ide%ti#"i%& !i%i ia%

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!eade$s #o$ mo$e ad(a% ed o%#!i t ma%a&eme%t &$oomi%& a% he!) i%#use o%#!i t ma%a&eme%t $o!e mode!s th$ou&hout the o$&a%i5atio%, 'ith the )ote%tia! to $eate 'ides)$ead u!tu$e ha%&e i% the o$&a%i5atio%- Ta))i%& se%io$ !i%i ia%s9 desi$e to !ea(e a !e&a " a% i% $ease 'i!!i%&%ess to o%t$ibute the e8t$a time a%d e##o$t to be ome a $o!e mode!-

Use "#isting Structures to Four dvantage+ Embeddi%& o%#!i t ma%a&eme%t t$ai%i%& 'ithi% the a))$e%ti eshi) mode!s o# hea!th a$e edu atio% a% he!) i%te&$ate o%#!i t e%&a&eme%t as a o$e )$o#essio%a! om)ete% "- Ado)ti%& the te$m B o6me%to$i%&,C as su&&ested b" Coh%, a% $edu e se%siti(it" to hie$a$ h", i% $easi%& the !i4e!ihood that se%io$ hea!th a$e )$a titio%e$s 'i!! 'a%t to )a$ti i)ate-231

Get People "arly+ I%t$odu i%& o%#!i t ma%a&eme%t at ea$!" sta&es o# medi a! a$ee$s i% $eases the !i4e!ihood that )ositi(e o%#!i t e%&a&eme%t 'i!! be ome %atu$a! #o$ )$o(ide$s- So!idi#"i%& the !ea$%i%& $e*ui$es $e&u!a$ #o!!o'6u) t$ai%i%&- Gai%i%& &$eate$ a ess to the time6st$a))ed medi a! a%d %u$si%& s hoo! u$$i u!a ma" %e essitate $e&u!atio% #$om edu atio%a! a $editi%& bodies-

Use Communication Courses as the ccess Point: Commu%i atio% ou$ses i% medi a! a%d %u$si%& s hoo!s se$(e as a 4e" e%t$"6)oi%t #o$ i%t$odu i%& basi o%#!i t ma%a&eme%t s4i!!s to

'ide audie% es- I% o$de$ to #a i!itate this, i%st$u to$s %eed to be &i(e% the $esou$ es to tea h basi o%#!i t ma%a&eme%t- P$e)a$ed o%#!i t ma%a&eme%t modu!es #o$ hea!th )$o#essio%a!

s hoo!s a% ma4e it easie$ #o$ su))o$ti(e i%st$u to$s to i% o$)o$ate this- S e%a$ios a%d $o!e )!a"s simi!a$ to those )$odu ed Ea%d so!dF b" edu ato$s #o$ use i% busi%ess s hoo! %e&otiatio% !asses shou!d be de(e!o)ed a%d made a(ai!ab!e to the hea!th )$o#essio%a! s hoo!s-

231

Je%%eth Coh%, BCo!!abo$ati(e Co6Me%to$i%&,C /u!" 0A, 233A, o%!i%e a$ti !e a(ai!ab!e at htt):GGhea!th a$e o!!abo$atio%- omG o!!abo$ati(e6 o6me%to$i%&G

033

Continuing "ducation Credit+ Co%#!i t ma%a&eme%t t$ai%i%&s %eed to *ua!i#" #o$ o%ti%ui%& edu atio% $edit i% o$de$ to i% $ease the !i4e!ihood that )$o(ide$s 'i!! be ab!e to atte%d o%#!i t ma%a&eme%t 'o$4sho)s-

(ow to Promote Conflict Management TrainingG

The *uestio% )osed to %ume$ous i%te$(ie'ees, B.hat ma4es hea!th a$e )$o(ide$s e8)e$ie% i%& o%#!i t 'a%t to ha%&e G 'a%t to atte%d a o%#!i t ma%a&eme%t t$ai%i%& G bu" i% to ADRIC )$odu ed (a$ied $es)o%ses- Ma%" said data sho'i%& the (a!ue o# o%#!i t ma%a&eme%t is im)o$ta%t, be ause hea!th a$e )$o(ide$s a$e )eo)!e 'ho te%d to thi%4 i% e(ide% e6based 'a"sA%othe$ i%te$(ie'ee im)!ied that data 'as use#u! but stated that )eo)!e do%9t de ide to atte%d t$ai%i%&s o$ see4 he!) 'ith o%#!i t ma%a&eme%t based o% data- I%stead, the d$i(e$s a$e mo$e !i4e!" to be #ea$ o$ a (is e$a! $es)o%se to o% e$%s 'ith mo%e", !e&a ", o$ a Dob at sta4e- To $ea h a !a$&e$ audie% e, the" su&&ested o%#!i t ma%a&eme%t ta) i% to these d$i(e$s-

A%othe$ ADR )$o#essio%a! %oted that bui!di%& t$ust i% the i%di(idua!s asso iated 'ith the ADR a ti(it" a%d i% the i%stitutio% Et$usti%& that it is o4a" to e%&a&e i% the )$o ess a%d dia!o&ueF is o#te% a 4e" e%ab!e$7 )$o(ide$s ma" #ee! a))$ehe%si(e a%d a%8ious about &etti%& i% t$oub!e as a $esu!t o# the o%#!i t, so the" must be $eassu$ed that )a$ti i)atio% i% the o%#!i t ma%a&eme%t a ti(ities does %ot e8)ose them to e8t$a $is4- C$eati%& o))o$tu%ities #o$ )$o(ide$s to ta!4 'ith )ee$s 'ho ha(e &o%e th$ou&h the )$o ess i% the )ast 'as %oted as he!)#u!-

Othe$s %oted that s4e)ti a! )$o(ide$s must )e$ ei(e the !o%&6te$m be%e#its o# )a$ti i)ati%& i% a o%#!i t ma%a&eme%t t$ai%i%& o$ )$o ess as hi&he$ tha% the immediate osts, !a$&e!" time a%d mo%e"- Su&&ested se!!i%& )oi%ts #o$ s4e)ti s i% !uded: sto$ies a%d ase studies i!!ust$ati%& its (a!ue7 the B*uiete$, *ui 4e$, hea)e$C att$ibutes o# o%#!i t ma%a&eme%t7 the %eed to )$ese$(e esse%tia! )$o#essio%a! $e!atio%shi)s Eas i% a

030

)$a ti e &$ou)F7 the abi!it" to o%t$o! the $eso!utio% )$o ess, add$essi%& the o%#!i t B'ithi% "ou$ o'% u!tu$e, amo%& "ou$ o'% 4i%dC7 a%d o%#!i t ma%a&eme%t %ot as a)itu!atio% but as a% o))o$tu%it" #o$ 'i%6'i% so!utio%s-

Additio%a! $e omme%datio%s #o$ )$omoti%& o%#!i t ma%a&eme%t i% !uded be&i%%i%& 'ith medi a! sta## mode$ates7 ide%ti#"i%& a%d &$oomi%& !i%i ia% !eade$s 'ho a$e i%te$ested7 edu ati%& hos)ita! admi%ist$ato$s to &a$%e$ su))o$t7 e%&a&i%& $is4 ma%a&e$s7 a%d edu ati%& hea!th !a' )$o(ide$sThese $e omme%datio%s mat hed ma%" o# those su&&ested i% the !ite$atu$e-

6. Merging t&e Cultures of Healt& Care and #ispute "esolution

Ada)ti%& ADR te$mi%o!o&", mode!s, a%d )a 4a&i%& #o$ the )a$ti u!a$ u!tu$es o# hea!th a$e 'i!! aid i% the )$o ess o# mai%st$eami%& hea!th a$e dis)ute $eso!utio%-

%o .o (arm

Hea!th a$e ADR shou!d i% $easi%&!" uti!i5e the !i%i a! ethi o# Do No Ha$m to sha)e the timi%& a%d #o$m o# ADR i%te$(e%tio%s- Fo$ma! ADR i%te$(e%tio%s a ti(ated th$ou&h o##i ia! ha%%e!s a% be dis$u)ti(e, usi%& sta## time, att$a ti%& u%desi$ed atte%tio%, a%d )ote%tia!!" th$eate%i%& $e!atio%shi)sThis is )a$ti u!a$!" the ase 'ith dis)utes i%(o!(i%& di##i u!t o6'o$4e$s o$ su)e$io$s- It is a!most im)ossib!e i% the mediatio% o%te8t to )$e(e%t the )ossibi!it" o# $eta!iatio% a&ai%st the )e$so% 'ho #o$ma!!" #i!ed the om)!ai%t7 e(e% subt!e #o$ms o# $eta!iatio% a% dest$o" a 'o$4)!a e $e!atio%shi)-

E##o$ts to mi%imi5e su h u%desi$ab!e im)a ts o# ADR i%te$(e%tio%s ma" i% $easi%&!" !ead the #ie!d a'a" #$om #o$ma! mediatio% to'a$ds i%#o$ma! o%#!i t oa hi%& mode!s a%d ea$!" i%te$(e%tio%s o%du ted

03 2

e%ti$e!" b" the hea!th a$e )$o(ide$s i%(o!(ed 'ith the ase- This mat hes a b$oade$ t$e%d i% the ADR #ie!d o(e$a!! a'a" #$om mediatio%6based mode!s to'a$ds o%#!i t oa hi%&-

The )$i% i)!e o# Do No Ha$m, t$aditio%a!!" #o used so!e!" o% )atie%ts a%d #ami!ies, e*ua!!" a))!ies to $e!atio%s 'ith hea!th a$e o!!ea&ues- A 4%o'!ed&i%& o'o$4e$s9 %eeds has the )ote%tia! to ha%&e s"stems that sustai% dis$u)ti(e beha(io$, abuse o# )o'e$, a%d dama&i%& hie$a$ hies i% hea!th a$e o$&a%i5atio%s-

The ADR motto B*uiete$, *ui 4e$, hea)e$C $eso%ates 'ith this Do No Ha$m ethi - .hi!e *uiete$ a%d mo$e o%#ide%tia! i%te$(e%tio%s )ose !ess $is4 o# $eta!iatio%, t$aditio%a! o%#!i t oa hi%& mode!s that as4 #o$ se$ious se!#6 $e#!e tio% o% the )a$t o# the )a$ti i)a%t a%d a !o%&6te$m time ommitme%t Eo#te% u) to a "ea$F to the oa hi%& )$o ess 'i!! #a e ha!!e%&es i% a time6 o%st$ai%ed hea!th a$e setti%&- To be $e!e(a%t to hea!th a$e, o%#!i t oa hi%& ma" %eed to e8)!o$e a!te$%ati(e, !ess6#o$ma! a(e%ues #o$ o%#!i t me%to$shi) that uti!i5e the o6'o$4e$s a%d su)e$io$s 'ith 'hom )$o(ide$s a!$ead" i%te$a t $e&u!a$!"-

See *ne- %o *ne- Teach *ne) 7amiliar Models for Teaching Conflict Management

The !ea$%i%& mode! o# See O%e, Do O%e, Tea h O%e is a de#i%i%& as)e t o# )h"si ia% edu atio%- P$o(ide$s a$e #ami!ia$ 'ith this !ea$%i%& st"!e a%d ADR t$ai%i%&s a% i% $easi%&!" uti!i5e this a))$oa h to i%te&$ate o%#!i t $eso!utio% s4i!!s i%to )$o(ide$s9 $e)e$toi$e- The medi a! stude%t6i%te$%6$eside%t6atte%di%& )h"si ia% )$o&$essio% i% the t$ai%i%& o# )h"si ia%s su&&ests a )$otot")e #o$ bui!di%& (a$ious tie$s o# o%#!i t $eso!utio% e8)e$tise 'ithi% %et'o$4s o# !i%i a! )$o(ide$s- This $e*ui$es both st$u tu$ed !ea$%i%& o))o$tu%ities a%d di##e$e%t t")es o# o%#!i t $eso!utio% t$ai%i%&s to add$ess the %eeds o# )$a titio%e$s at di##e$e%t !e(e!s o# e8)e$tise i% the #ie!d- Mode!i%& o# e##e ti(e o%#!i t $eso!utio% s4i!!s, o))o$tu%ities #o$ )$a ti e, &uided !ea$%i%&, a%d $e&u!a$ #eedba 4 a$e im)o$ta%t #o$ )$o&$essi(e!" bui!di%& e8)e$tise-

03 ;

Fo$ma! ha%%e!s #o$ &$oomi%& !eade$s i% hea!th a$e o%#!i t $eso!utio% a% he!) i%stitutio%a!i5e this mode!- Those 'ith the i%te$est a%d a)titude to se$(e as me%to$s to othe$s ou!d be se!e ted #o$ o%#!i t $eso!utio% t$ai%i%&s at the basi , ad(a% ed, a%d t$ai%i%&6o#6t$ai%e$s !e(e!s- This a))$oa h has the )ote%tia! to b$i%& about 'ides)$ead shi#ts i% a 'o$4)!a e a%d its a om)a%"i%& )$o#essio%a! u!tu$e-

Estab!ishi%& #o$ma! o$ i%#o$ma! ommu%ities o# )$a ti e is a%othe$ o))o$tu%it" to #a i!itate me%to$shi) a%d &uided !ea$%i%& o))o$tu%ities i% hea!th a$e o%#!i t $eso!utio%- These ommu%ities o# )$a ti e ou!d ta4e ma%" #o$ms a%d ma" $e(o!(e a$ou%d %ume$ous a8es- I# desi$ed, outside ADR e8)e$ts a% a!so )a$ti i)ate- The 4e" is )$o(idi%& $e&u!a$ o))o$tu%ities #o$ o%su!tatio%, sha$i%& e8)e$ie% es, $e#!e tio%, a%d $ei%#o$ eme%t o# !ea$%i%&- Fo$ sustai%abi!it", the o'%e$shi) o# su h ommu%ities o# )$a ti e must $est e%ti$e!" 'ith the membe$s themse!(es, thou&h i%stitutio%s a% e% ou$a&e a%d su))o$t su h ommu%ities as a))$o)$iate-

Conflict Resolution Mainstreaming) Good Communication as the "ntry Point

To he!) mai%st$eam o%#!i t $eso!utio% i% hea!th a$e, o%#!i t $eso!utio% )$a titio%e$s shou!d be 'i!!i%& to $e6)a 4a&e thei$ o%t$ibutio%s to #it the te$mi%o!o&" a%d u!tu$es o# hea!th a$e- I% )a$ti u!a$, o%#!i t $eso!utio% a% a ti(e!" use hea!th a$e9s o% e$% 'ith B ommu%i atio%C as the e%t$" )oi%t #o$ i%t$odu i%& o%#!i t $eso!utio% s4i!!s a%d te h%i*ues i%to edu atio%a! u$$i u!a, e$ti#ied o%ti%ui%& edu atio% t$ai%i%&, hos)ita! o)e$ati%& )$oto o!s, a%d the o(e$a!! u!tu$e o# hea!th a$e-

Co%#!i t $eso!utio% #ie!ds a%d hea!th a$e #ie!ds o#te% s)ea4 di##e$e%t !a%&ua&es- I% the #a e o# s4e)ti ism o% the )a$t o# ma%" hea!th a$e )$o(ide$s to'a$ds the (a!ue o# o%#!i t $eso!utio%, te$mi%o!o&" is im)o$ta%t- Co%#!i t $eso!utio% te$ms des $ibi%& i%ta%&ib!e o% e)ts, $e!atio%shi)s, a%d )$o esses a% seem o(e$!" Bso#t,C )a$ti u!a$!" to those hea!th a$e )$a titio%e$s t$ai%ed to s"stemati a!!" a%a!"5e a%d )$o ess data- Additio%a!!", i% ma%" hea!th a$e o%te8ts mu h o# the dis)ute $eso!utio% #ie!d a%d its te$mi%o!o&" has

03=

o(e$!" !e&a! o%%otatio%s that do %ot mat h the b$eadth o# s4i!!s a%d te h%i*ues that dis)ute $eso!utio% a% b$i%& to hea!th a$e-

No hea!th a$e )$o(ide$s i%te$(ie'ed #o$ this thesis used the te$ms dia!o&ue, %e&otiatio%, mediatio%, o%#!i t $eso!utio%, E o%#!i tF oa hi%&, i%te$ests E(s- )ositio%sF, o$ %eut$a! du$i%& thei$ i%te$(ie's, e(e% 'he% des $ibi%& )$o esses that !ose!" i%(o!(ed these a ti(ities a%d ideas- Mo$eo(e$, ma%" i%te$(ie'ees omme%ted that the" do %ot see o$ e8)e$ie% e B o%#!i tC i% thei$ 'o$4 e%(i$o%me%t, be#o$e )$o eedi%& to des $ibe Be% ou%te$s,C Bi% ide%ts,C a%d Be8)e$ie% esC that this autho$ ou!d o%!" des $ibe as o%#!i t-

I%stead, hea!th a$e )$o(ide$s ha(e )$ob!ems 'ith B ommu%i atio%-C BGood ommu%i atio%C 'as #$e*ue%t!" hea$d as the 4e" )h$ase i% ma%" o# the i%te$(ie's a%d mu h o# the !ite$atu$e $e!ated to hea!th a$e o%#!i t $eso!utio%- The te$m B)$o ess s4i!!sC 'as o#te% used 'he% des $ibi%& te h%i*ues o# dia!o&ue, %e&otiatio%, mediatio%, a%d othe$ #o$ms o# o%#!i t $eso!utio%- The o% e)ts o# ommu%i atio% a%d )$o ess s4i!!s a!$ead" ha(e t$a tio% 'ithi% the hea!th a$e #ie!d, ma4i%& them a ess )oi%ts #o$ o%#!i t $eso!utio% that shou!d be a)ita!i5ed o%-

Productive Conflict

Co%#!i t $eso!utio% )$a titio%e$s shou!d mo$e e8)!i it!" $aise a'a$e%ess amo%& hea!th a$e sta4eho!de$s o# the )ossibi!ities #o$ ha$%essi%& o%#!i ts a%d di##e$e% es o# o)i%io% as )$odu ti(e a%d )ositi(e #o$ es i% hea!th a$eGi(e% that o%#!i t is a o%sta%t a%d i%e(itab!e )$ese% e i% om)!e8 s"stems o# i%te$a tio% su h as hea!th a$e, the $e o&%itio% that o%#!i t a% be emb$a ed as a d$i(e$ #o$ i%%o(atio% a%d im)$o(eme%t a% $e(o!utio%i5e ho' ma%" hea!th a$e )$o(ide$s o% e)tua!i5e thei$ $e!atio%shi)s 'ith othe$s i% the hea!th a$e e%(i$o%me%t- The omme%ts o# %ume$ous i%te$(ie'ees a%d mu h o# the !ite$atu$e su&&est that hea!th a$e )$o(ide$s a% a))$e iate the idea o# )$odu ti(e o%#!i t, but &$eate$ out$ea h is %eeded-

03 1

Ca)tu$i%& the )ositi(e )o'e$ o# di##e$e%t )e$s)e ti(es E)$odu ti(e o%#!i tF ma" $e*ui$e $e o% e)tua!i5i%& the $o!es o# )$o(ide$s (is a (is )atie%ts, othe$ )$o(ide$s, a%d othe$ sta4eho!de$sRe!atio%shi)s based o% #ea$, autho$it", a%d d$amati )o'e$ imba!a% es i%(o!(i%& !a$&e &a)s i% a ess to i%#o$matio% a%d $i&id )$o#essio%a! hie$a$ hies ma4e o%se%sus bui!di%&, )a$ti i)ato$"

de isio% ma4i%& a%d i%stitutio%a! !ea$%i%& mo$e di##i u!t7 setti%&s ha$a te$i5ed b" su h $e!atio%shi)s 'i!! st$u&&!e to ma%a&e o%#!i t )$odu ti(e!"- Su))o$ti%& t$e%ds to'a$ds a 4%o'!ed&i%& the huma%it" o# hea!th a$e )$o(ide$s, $e o&%i5i%& thei$ (e$" huma% !imitatio%s o% 4%o'!ed&e a%d mista4es, a%d u%de$sta%di%& the o%st$ai%ts a%d $es)o%sibi!ities o# othe$ a to$s i% the hea!th a$e s"stem 'i!! he!) o)e% a(e%ues #o$ emb$a i%& om)!e8it" a%d a)ita!i5i%& o% the )$ese% e o# di##e$e%t )e$s)e ti(es-

Co%#!i t $eso!utio% )$o#essio%a!s a% he!) )$o(ide$s !ea$% ho' to emb$a e e$tai% t")es o# o%#!i t b" hi&h!i&hti%& ho' o%#!i t a!$ead" #u% tio%s )ositi(e!" i% thei$ e(e$"da" a ti(ities- Dis !osu$e o# ad(e$se out omes has )$o(e% a )o'e$#u! #o$ e #o$ im)$o(i%& the s"stems a%d )$oto o!s that a!!o'ed those e(e%ts to o u$- Fa i!itati%& st$u tu$ed dia!o&ue bet'ee% admi%ist$ato$s a%d di##e$e%t t")es o# )$o(ide$

&$ou)s s)u$s $eati(it" a%d dee)e%s u%de$sta%di%& o# om)!e8 s"stems- A%d )$o(ide$s i% $easi%&!" emb$a e the *uestio%s a%d obse$(atio%s o# )atie%ts a%d #e!!o' )$o(ide$s as a $esou$ e to a!e$t the )$o(ide$ to 4e" de(e!o)me%ts o$ i%#o$matio% that the" ma" ha(e missed- Usi%& these o%te8ts to i!!ust$ate )ositi(e o%#!i t a% he!) hea!th a$e )$o(ide$s $e#$ame ho' the" (ie' disa&$eeme%t a%d $e o&%i5e ho' the" a% )$odu ti(e!" ha$%ess it-

%ispute Resolution) .ot $ust for Lawyers

Fu$the$ i%te&$ati%& o%#!i t $eso!utio% i%to the hea!th a$e o%te8t is !i4e!" to e8)a%d the de#i%itio% o# 'hat it mea%s to be *ua!i#ied as a% ADR )$o#essio%a!- As !i%i ia%s i% $easi%&!" om)!eme%t the% su))!a%t !e&a!!"6t$ai%ed ADR )$o#essio%a!s as the #$o%t !i%e i% hea!th a$e o%#!i t ma%a&eme%t, the em)hasis a%d a))$oa h o# hea!th a$e ADR ma" shi#t- Hea!th a$e )$o(ide$s b$i%& %e' )e$s)e ti(e, t$ai%i%&, a%d

03<

)$o#essio%a! u!tu$e to hea!th a$e o%#!i t ma%a&eme%t that ma" &e%e$ate u%i*ue #$ame'o$4s #o$ i%te$a tio%, di##e$e%t o% e)tua! i%si&hts, a%d a!te$%ati(e edu atio%a! a%d t$ai%i%& a(e%ues #o$ estab!ishi%& $edibi!it" as a% ADR e8)e$t-

'ncreased Collaboration between clinical staff and nonAclinical %R professionals

C!i%i a! sta## a% )!a" im)o$ta%t $o!es i% desi&%i%&, o%du ti%&, a%d i%te$)$eti%& #utu$e $esea$ h i% hea!th a$e o%#!i t $eso!utio%- I% $easi%& the #eedba 4, e8 ha%&e o# ideas, a%d o!!abo$atio% bet'ee% %o%6medi a! ADR )$o#essio%a!s a%d !i%i a! sta## 'i!! he!) im)$o(e hea!th a$e o%#!i t $eso!utio% s"stems, i%te$(e%tio%s, a%d t$ai%i%&s- A essi%& !i%i ia%s9 )e$s)e ti(es 'i!! ad(a% e the #ie!d as the" he!) $ea!it"6 he 4 %o%6medi a! ADR

)$o#essio%a!s $e&a$di%& the o%#!i ts #$o%t6!i%e medi a! $es)o%de$s $e&u!a$!" #a e, ho' the" a$e a tua!!" usi%& o%#!i t $eso!utio% s4i!!s i% these o%#!i ts, thei$ e8)e$ie% es 'ith (a$ious te h%i*ues, ba$$ie$s to im)!eme%tatio%, u%met %eeds, a%d su&&estio%s #o$ im)$o(eme%ts-

7. Suggested uture "esearc&

Fo!!o'i%& a$e su&&estio%s #o$ #utu$e $esea$ h- O% a!! to)i s, it is $e omme%ded that the hea!th a$e o%#!i t $eso!utio% #ie!d e8)!o$e ho' to bette$ a)tu$e its *ua!itati(e data, 'hi!e a!so !oo4i%& to e8)a%d the *ua%titati(e data that is bei%& o!!e ted-

Relationships: Sua!itati(e $esea$ h is %eeded to a)tu$e the !o%&6te$m im)a ts o# o%#!i t $eso!utio% o% the ha%&e i% $e!atio%shi)s i% hea!th a$e- Su h $esea$ h 'i!! be )a$ti u!a$!" (a!uab!e to he!) e8)!o$e the im)!i atio%s o# the o% e)tua! shi#t a'a" #$om i%te$est6based mode!s to'a$ds $e!atio%shi)6based mode!s- De o%st$u ti%& the d"%ami bet'ee% o%#!i t a%d $e!atio%shi)s 'i!! be ha!!e%&i%& but o##e$s (a!uab!e i%si&hts that ma" )$odu e %e' mode!s, #$ame'o$4s, a%d desi&%s #o$ o%#!i t ma%a&eme%t s"stems- .hat does it mea% to shi#t #$om i%te$est6 based mode!s to $e!atio%shi)6based mode!sI .hat does it ha%&e about

03@

ho' 'e a))$oa h the )a$adi&m o# hea!th a$e o%#!i tsI .hat de#i%es su

ess 'ith

$e!atio%shi)6based o%#!i t $eso!utio%I These a%d $e!ated o% e)tua! *uestio%s 'i!! be at the #$o%t o# #o$th omi%& o%#!i t $eso!utio% $esea$ h-

Training 'mpact) Resea$ h is %eeded to measu$e the !o%&6te$m im)a ts o# o%#!i t $eso!utio% t$ai%i%& i% the u$$i u!a o# %u$si%& s hoo!s, medi a! s hoo!s, $eside% ies, a%d i%te$6)$o#essio%a! t$ai%i%&s- 23< E8)!o$i%& the im)a t o# mode!i%& a%d the medi a! $eside% " e8)e$ie% e o% the $ete%tio% o# o%#!i t ma%a&eme%t s4i!!s !ea$%ed du$i%& medi a! s hoo! ou!d be )a$t o# $esea$ h #o used o% 'he% to best ta$&et o%#!i t ma%a&eme%t t$ai%i%& Edu$i%& )$o#essio%a! s hoo!, $eside% ", o$ o%ti%ui%& edu atio%FAdditio%a! $esea$ h *uestio%s i% !ude the im)a t o# ma%dato$" (e$sus e!e ti(e t$ai%i%&7 the !o%&6te$m im)a ts o# di##e$e%t t$ai%i%& de!i(e$" me ha%isms Eo%!i%e, st$u tu$ed me%to$i%&, e8)e$ie%tia! 'o$4sho), et -F7 a%d 'a"s to ombi%e t$ai%i%& 'ith oa hi%& a%d i%te%tio%a! ommu%ities o# )$a ti e-

Costs of Conflict) Measu$i%& the a tua! osts o# o%#!i t a!! #o$ mi8ed methodo!o&ies- C!aims that )$o(ide$s s)e%d 13K o# thei$ time i% o%#!i t a$$" e%o$mous #i%a% ia! im)!i atio%s #o$ the hea!th a$e #ie!d- Disa&&$e&ati%& ho' this time is s)e%t a%d do ume%ti%& the time a%d mo%e" !ost to o%#!i t is a% im)o$ta%t $esea$ h to)i -

Comple# Systems Research) Com)!e8it" a%d om)!e8 s"stems $esea$ h ha(e eme$&ed as im)o$ta%t to)i s o# stud" i% a (a$iet" o# dis i)!i%es- Hea!th a$e is a )$ime e8am)!e o# a om)!e8 ada)ti(e s"stem a%d e$tai% as)e ts o# hea!th a$e ha(e bee% e8ami%ed th$ou&h a om)!e8it" !e%s- Ho'e(e$, the$e $emai% o))o$tu%ities to mo$e e8)!i it!" e8)!o$e the !i%4 bet'ee% hea!th a$e o%#!i t a%d s"stem om)!e8it"- Su h $esea$ h ma" o##e$ additio%a! )e$s)e ti(es o% the )ossib!e $o!e o# huma% $e!atio%shi)s as the ba 4bo%e !i%4i%& ma%" othe$'ise dis)a$ate )$o esses a%d su))o$t st$u tu$es i% hea!th a$e-

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P'eibe!, et a!-, B.hat Sti 4s,C )- ;=<03A

(ealthcare %elivery Science and Conflict Management: The $est$u tu$i%& o# hea!th a$e de!i(e$" s"stems is t$a%s#o$mi%& $e!atio%shi)s bet'ee% hea!th a$e )$o(ide$s- Hea!th a$e o%#!i ts a%d e##i ie%t $es)o%ses to them a$e $u ia! om)o%e%ts o# these %e' s"stems- Hea!th a$e de!i(e$" s ie% e a%d its $e!atio%shi) to hea!th a$e o%#!i t 'i!! o%ti%ue to &$o' as a $obust a$e%a #o$ #utu$e $esea$ h-

Conflict Management 'mpacts) Fu$the$ $esea$ h is %eeded to st$e%&the% the !aim that e##e ti(e o%#!i t e%&a&eme%t auses:

1. Im)$o(ed !i%i a! out omes 2. I% $eased )atie%t sa#et" 3. I% $eased )atie%t satis#a tio% 4. I% $eased sta## $ete%tio% G im)$o(ed sta## mo$a!e 5. Fi%a% ia! be%e#it to a )$a ti eG#a i!it"Gs"stem E!o'e$ osts, hi&he$ $e(e%uesF 6. Time sa(i%&s #o$ )$o(ide$s

Su h $esea$ h 'i!! %eed to de#i%e 'hat is mea%t b" e##e ti(e o%#!i t e%&a&eme%t a%d 'hat as)e t o# o%#!i t e%&a&eme%t is bei%& measu$ed b" the $esea$ h-

Ce$tai% as)e ts o# hea!th a$e dis)ute $eso!utio% a!! #o$ $esea$ h that add$esses *uestio%s i% additio% to those abo(e-

%isclosure: Resea$ h s)e i#i to dis !osu$e mo(eme%ts is %eeded to measu$e:

1. The di##e$e% e i% im)a t bet'ee% #u!!6a)o!o&" dis !osu$e a%d )a$tia!6a)o!o&" dis !osu$e2. The #i%a% ia! im)a t o# )$oa ti(e #u!! dis !osu$e )$o&$ams, i% the a tua! e8)e$ie% e o#
i%stitutio%s im)!eme%ti%& su h )$o&$ams- Measu$i%& ho' )$oa ti(e dis !osu$e a!te$s the %umbe$ o# ma!)$a ti e ases #i!ed a%d a##e ts sett!eme%t $ates a%d om)e%satio% osts 'i!! be )a$ti u!a$!" (a!uab!e-

03?

Shared %ecision Ma!ing: Resea$ h o% Sha$ed De isio% Ma4i%& is %eeded to do ume%t the im)a t that the

use o# sha$ed de isio% ma4i%& aids has o%:

1. A!te$i%& the amou%t a%d *ua!it" o# time di##e$e%t t")es o# )$o(ide$s s)e%d 'ith )atie%ts 2. O)e$atio% $ates #o$ s)e i#i )$e#e$e% e6se%siti(e )$o edu$es

%isruptive 4ehavior) Fu$the$ $esea$ h is %eeded o% the !aims that:

1. Dis$u)ti(e beha(io$ %e&ati(e!" im)a ts )atie%t sa#et" 2. Dis$u)ti(e beha(io$ %e&ati(e!" im)a ts sta## $ete%tio%

om)a%"i%& $esea$ h a% he!) *ua%titati(e!" measu$e the osts asso iated 'ith a!! o#

these ha%&es a$isi%& #$om the o%#!i t i%te$(e%tio%-

'ncreased Publication of Stories and 7indings

The$e is a o%ti%ued %eed #o$ hea!th a$e o%#!i t $eso!utio% )$o#essio%a!s to sha$e e8)e$ie% es, ase studies, a%d su ess sto$ies to a 'ide$ audie% e- Nume$ous i%te$(ie'ees ited thei$ desi$e #o$ ase studies i!!ust$ati%& that )$o ess s4i!!s Ei% %e&otiatio%, mediatio%, dia!o&ue, a ti(e !iste%i%&F 'o$4 i% hea!th a$e- Othe$ )$o#essio%a!s e8)$essed thei$ desi$ed to !ea$% mo$e about i%%o(ati(e a))$oa hes to o%#!i t eme$&i%& #$om di##e$e%t &$ou)s i% hea!th a$e E%u$ses, )h"si ia%s, admi%ist$ato$s, i%su$a% e )$o(ide$s, hos)ita!s, ma%a&ed a$e o$&a%i5atio%s, et -F, #$om di##e$e%t &eo&$a)hi a! $e&io%s, a%d #$om )eo)!e 'o$4i%& o% di##e$e%t as)e ts o# o%#!i t i% hea!th a$e-

Nume$ous i%te$(ie'ees su&&ested o!!e ti%& ase studies a%d su ess sto$ies i%to a boo4 ta$&eted #o$ hea!th a$e )$o(ide$s, es)e ia!!" ases i!!ust$ati%& ho' e##e ti(e o%#!i t e%&a&eme%t !ed to )$o#ou%d im)a ts o$ 'ides)$ead u!tu$e ha%&e i% a hea!th a$e o%te8t-

003

A se o%d $e omme%datio% is to assemb!e ase studies a%d )$oDe t them i%to o%#!i t $eso!utio% tea hi%& modu!es that ou!d be uti!i5ed as )a$t o# a medi a! s hoo! o$ %u$si%& s hoo! ou$se o% ommu%i atio%- Ne&otiatio% s e%a$ios desi&%ed b" (a$ious busi%ess s hoo!s #o$ )u$ haseGuse b" othe$ i%st$u to$s tea hi%& ou$ses o% %e&otiatio% se$(e as a% e8am)!e o# ho' su h o%#!i t $eso!utio% s e%a$ios ou!d be desi&%ed a%d used-

000

CO!CLUSIO!

The #i%di%&s su&&est that di(idi%& hea!th a$e o%#!i t i%to $e!atio%shi)6based ate&o$ies o# o%#!i t is a))$o)$iate due to si&%i#i a%t di##e$e% es i% the t")es o# o%#!i t e8)e$ie% ed i% these d"%ami s a%d the o$$es)o%di%& di##e$e% es i% o%#!i t ma%a&eme%t &oa!s a%d i%te$(e%tio%s- Co%#!i t ma%a&eme%t i%te$(e%tio%s i% a!! o# the #ou$ d"%ami s !a$&e!" sha$ed the aims o# im)$o(i%& $e!atio%shi)s, im)$o(i%& ommu%i atio%, a%d sa(i%& mo%e", thou&h ea h d"%ami i% !uded additio%a! aims- S)e i#i de#i%itio%s o# su ess (a$ied, at times 'ide!"- The$e is a %ote'o$th" di##e$e% e i% o%te8t a%d )e$s)e ti(e bet'ee% t'o o# the !a$&est ate&o$ies o# hea!th a$e o%#!i t, )atie%t6)$o(ide$ ad(e$se out ome o%#!i t a%d )$o(ide$6)$o(ide$ o%#!i t- Patie%t6)a"e$ o%#!i t i%te$(e%tio%s di##e$ed #$om the othe$s i% bei%& !ess $e!atio%a! a%d mo$e t$a%sa tio%a!- Ea$!" i%te$(e%tio% i% o%#!i t ma%a&eme%t 'as im)o$ta%t i% a!! d"%ami s-

The !ite$atu$e $e(ie' a%d i%te$(ie' data a!so ide%ti#ied im)o$ta%t o%te8tua! #eatu$es o# hea!th a$e o%#!i t- The im)a t o# hea!th a$e u!tu$e a%d its )$o#essio%a! sub u!tu$es o% o%#!i ts a%d o%#!i t ma%a&eme%t is si&%i#i a%tThe o%#!i t ma%a&eme%t $o!es o# hea!th a$e )$o(ide$s (a$" si&%i#i a%t!" i% di##e$e%t d"%ami s a%d at di##e$e%t sta&es o# i%te$(e%tio%, thou&h the" a$e i% $easi%&!" e8)e ted to )!a" !eadi%& $o!es i% o%#!i t ma%a&eme%t a $oss a!! d"%ami s- .hi!e #a i!itatio% a%d o%#!i t oa hi%& i%te$(e%tio%s 'e$e )$omi%e%t i% a!! d"%ami s, o%!" i% ad(e$se6 e(e%t dis !osu$e 'as mediatio% a )$omi%e%t mode! #o$ i%te$(e%tio%- A!! othe$ t$e%ds )oi%ted to'a$ds ea$!" sta&e, hea!th a$e )$o(ide$6!ed i%te$(e%tio%s-

Im)o$ta%t t$e%ds i% hea!th a$e o%#!i t ma%a&eme%t ide%ti#ied b" the $esea$ h i% !ude a% i% $eased #o us o% $e!atio%shi)s a%d $e!atio%shi)6based a))$oa hes to o%#!i t ma%a&eme%t7 a $eo$ie%tatio% to'a$ds )$e(e%tio% a%d ea$!" i%te$(e%tio%7 i% $easi%& e8)e tatio%s that hea!th a$e )$o(ide$s !ead o% o%#!i t e%&a&eme%t, su))!a%ti%& thi$d6)a$t" i%te$(e%tio% mode!s7 attem)ts to bette$ a!i&% o%#!i t ma%a&eme%t 'ith hea!th a$e ide%tities, the )$i% i)!e o# Do No Ha$m, a%d the See O%e, Tea h O%e, Do O%e edu atio%a! mode!7 %e' #o$ms o# o%#!i t ma%a&eme%t edu atio% i%(o!(i%& me%to$shi)Gmode!i%& a%d the #o$matio% o# i%te%tio%a!

002

ommu%ities o# )$a ti e7 shi#ts to'a$ds !ess #o$ma! o%#!i t oa hi%& o(e$ mo$e #o$ma! mediatio%7 i% $eased %eeds #o$ o%#!i t ma%a&eme%t s4i!!s #o$ use i% di##i u!t o%(e$satio%s a$isi%& #$om mai%st$eami%& o# ad(e$se e(e%t dis !osu$e )o!i ies-

The $esea$ h su&&ests that )$a titio%e$s i% $ease the amou%t o# o!!abo$atio% bet'ee% ADR )$o#essio%a!s a%d !i%i ia%s o% o%#!i t ma%a&eme%t $esea$ h a%d t$ai%i%& desi&%7 e8)a%d the s o)e o# o%#!i t ma%a&eme%t s"stems to i% !ude othe$ t")es o# o%#!i t that ma" u$$e%t!" be i&%o$ed7 i%te&$ate o%#!i t ma%a&eme%t s"stems 'ith HR a%d !eade$shi) st$u tu$es7 su))o$t ommu%ities o# )$a ti e7 e%su$e that o%#!i t ma%a&eme%t s"stems a$e st$u tu$es a$e (isib!e a%d u%de$stood b" a!! sta##7 !oo4 to'a$ds !ess dis$u)ti(e mode!s o# i%te$(e%tio% that a$e mo$e a!i&%ed 'ith hea!th a$e u!tu$e7 a%d a ommodate the shi#t to'a$ds hea!th a$e )$o(ide$s as the #$o%t !i%e i% hea!th a$e o%#!i t ma%a&eme%t-

The su&&estio%s o# this thesis a$$" the #o!!o'i%& )o!i " im)!i atio%s: ada)ti%& the %atio%a!6!e(e! a%d state6!e(e! !e&a! #$ame'o$4s a##e ti%& ad(e$se out ome dis !osu$e to )$omote a)o!o&" a%d mi%imi5e st$u tu$a! disi% e%ti(es to t$a%s)a$e% "7 i% !udi%& s4i!!s #o$ e##e ti(e o%#!i t ma%a&eme%t as )$o#essio%a! om)ete% ies #o$ hea!th a$e )$o(ide$s7 ma%dati%& modu!es o% o%#!i t ma%a&eme%t i% )$o#essio%a! s hoo!s a%d $eside% " )$o&$ams7 e%ab!i%& o%#!i t ma%a&eme%t t$ai%i%&s to *ua!i#" #o$ hea!th a$e )$o(ide$s9 o%ti%ui%& edu atio% hou$s7 e%#o$ i%& the /oi%t Commissio% sta%da$ds #o$ o%#!i t ma%a&eme%t s"stems i% o$&a%i5atio%s7 #u%di%& #u$the$ $esea$ h o% hea!th a$e o%#!i t7 a%d %atio%a!6!e(e! #u%di%& #o$ )i!ot o%#!i t ma%a&eme%t )$o&$ams 'ith e8te%si(e data o!!e tio% a%d )ub!i !"6a(ai!ab!e $esu!ts-

00;

+I+LIOGRAPHX
Ame$i a% Hea!th La'"e$s Asso iatio%- Conflict Management Tool!it E233?Fhtt):GG'''-hea!th!a'"e$s-o$&GResou$ esGADRGPa&esGADRToo!4it-as)8 Ea essed 2? Ma" 2303F-

Ame$i a% So iet" #o$ Hea!th a$e Ris4 Ma%a&eme%t- %isclosure of Unanticipated "vents) The .e#t Step in 4etter Communication =part one of three>+ Chi a&o: Ame$i a% Hos)ita! Asso iatio% ENo(embe$ 233;Fhtt):GG'''-ash$m-o$&Gash$mGedu atio%Gde(e!o)me%tGmo%o&$a)hsG Ea essed 01 Ma" 2303F-

%isclosure of Unanticipated "vents) Creating an "ffective Patient Communication Policy =part two of three>+ Chi a&o: Ame$i a% Hos)ita! Asso iatio% ENo(embe$ 233;Fhtt):GG'''-ash$m-o$&Gash$mGedu atio%Gde(e!o)me%tGmo%o&$a)hsG Ea essed 01 Ma" 2303F-

A%de$so%, Co!b", a%d Li%da D9A%to%io- BEm)i$i a! I%si&hts: U%de$sta%di%& the U%i*ue Cu!tu$e o# Hea!th Ca$e Co%#!i t-C %ispute Resolution Maga&ine EFa!! 233=F: 0160ABA Pa$ti i)ato$" A))$oa h to U%de$sta%di%& Co%#!i t i% Hea!th a$e-C Georgia State University Law Review 20, %o- A0@ E2331F: A0@6A;3A5ou!e", E!ie, et a!-- BP$e(a!e% e a%d Fa to$s i% I%te%si(e Ca$e U%it Co%#!i ts The Co%#!i us Stud"-C

merican $ournal of Respiratory and Critical Care Medicine 0A3 E233?F: A1;A<3+a! e$5a4, Ga$" a%d Jath$"% Leo%ha$dt- BA!te$%ati(e Dis)ute Reso!utio% i% Hea!th a$e: A P$es $i)tio% #o$ I% $easi%& Dis !osu$e a%d Im)$o(i%& Patie%t Sa#et"-C Patient Safety and /uality (ealthcare E/u!"GAu&ust 233AF+u 4!e", Mi hae!, /oh% Lau$se%, a%d Li to$ia Ota$o!a- BSt$e%&the%i%& Ph"si ia%6Nu$se Pa$t%e$shi)s to Im)$o(e Sua!it" a%d Patie%t Sa#et"-C Physician "#ecutive $ournal of Medical Management

ENo(GDe 233?F: 2=62Ahtt):GG%et-a )e-o$&GMembe$sO%!"G)eDou$%a!G233?GNo(De G+u 4!e"MMi hae!-)d# Ea essed 2A Ma" 2303F+ush, Robe$t A-, a%d /ose)h P- Fo!&e$- The Promise of Mediation+ Sa% F$a% is o: /osse"6+ass, 0??=Ca$$, Susa%- BDis !osu$e a%d A)o!o&": .hat9s Missi%&I Ad(a% i%& P$o&$ams that Su))o$t C!i%i ia%s-C Patient Safety and /uality (ealthcare EMa$ hGA)$i! 2303F- '''-)s*h- omGma$ ha)$i!62303G=126dis !osu$e6a%d6 a)o!o&"6'hats6missi%&-htm! Ea essed 01 Ma" 2303F-

Che$$", Robe$t, Le%%" Ma$ us, a%d +a$$" Do$%- BRe)o$ti%& Ad(e$se E(e%ts to Patie%ts: A Ste) 6b"6 Ste) A))$oa h-C Physician "#ecutive $ournal of Medical Management EMa"G/u%e 2303F: =6?-

C!a$4, Jath!ee%- BAd(o a " i% Hea!th Ca$e: A Sam)!e o# State a%d P$i(ate S"stems-C %ispute Resolution Maga&ine 0<, %o- ; ES)$i%& 2303F: 03602Coh%, Je%%eth- BMedi a! Sta## Re!atio%s-C San %iego Physician+org E/u%e 233AF: 2=6;2BCo!!abo$ati(e Co6Me%to$i%&-C O%!i%e a$ti !e E/u!" 0A, 233AF a(ai!ab!e at htt):GGhea!th a$e o!!abo$atio%- omG o!!abo$ati(e6 o6me%to$i%&G-

Coh%, Je%%eth a%d Mi hae! Peet5- BSu$&eo% F$ust$atio%: Co%tem)o$a$" P$ob!ems, P$a ti a! So!utio%s-C Contemporary Surgery 1?, %o- 2 EFeb 233;F: @<6A1-

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Coh%, Je%%eth, Thomas A!!"%, a%d Robe$t Reid- BSt$u tu$ed Dia!o&ue +et'ee% Ph"si ia%s a%d Admi%ist$ato$s Xie!ds Positi(e Resu!ts-C The Physician "#ecutive E/u!"GAu&ust 233<F: 22621Coh%, Je%%eth, Leo%a$d F$iedma%, a%d Thomas A!!"%- BThe Te to%i P!ates a$e Shi#ti%&: Cu!tu$a! Cha%&e (sMu$a! D"s!e8ia-C 7rontiers of (ealth Services Management 2=, %o- 0 EFa!! 233@F: 0062<Coh%, Je%%eth, +$u e +etha% ou$t, a%d Mai$e Simi%&to%- BThe Li#e!o%& Ite$ati(e P$o ess o# Ph"si ia% Rete%tio%-C $ournal of (ealthcare Management 1=, %o- =, E/u!"GAu&ust 233?F: 223622<-

Coo4, A%% F$eema% a%d He!e%a Hoas- BEthi s Co%#!i ts i% Ru$a! Commu%ities: Re o&%i5i%& a%d Dis !osi%& Medi a! E$$o$s-C I% (andboo! for Rural (ealthcare "thics- edited b" .i!!iam ANe!so%, 2;2621;- T$ustees o# Da$tmouth Co!!e&e: Ha%o(e$, NH, 233?htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG ha)te$602-)d# Ea essed 0= Ma" 2303FCoo!e", /oh%- BA dose o# ADR #o$ the hea!th a$e i%dust$"-C %ispute Resolution $ournal 1@, %o- 0 EFeb$ua$"GA)$i! 2332F: 0=623Daue$, Ed'a$d- BPosts $i)t o% Hea!th Ca$e Dis)ute Reso!utio%: Co%#!i t Ma%a&eme%t a%d the Ro!e o# Cu!tu$e-C Georgia State University Law Review 20, %o- = ESumme$ 2331F: 032?6031=-

De)a$tme%t o# Lete$a%s A##ai$s- %isclosure of dverse "vents to Patients) 0( %irective 299@A9B;

EO tobe$ 2@, 2331F- .ashi%&to%, DC: Lete$a%s Hea!th Admi%ist$atio%Ede!stei%, Lau$e%, E(a% DeRe%5o, E!i5abeth .aet5i&, C$ai& Pe!i5e$, a%d N%e4a Mo4'u%"eBCommu%i atio% a%d Co%#!i t Ma%a&eme%t T$ai%i%& #o$ C!i%i a! +ioethi s Committees-C ("C 7orum 20, %o- = EDe embe$ 233?F: ;=06;=?Ga!!a&he$, Thomas, Am" .ate$ma%, A!iso% Ebe$s, Li to$ia F$ase$, a%d .e%d" Le(i%so%BPatie%ts9 a%d Ph"si ia%s9 Attitudes Re&a$di%& the Dis !osu$e o# Medi a! E$$o$s-C $ournal of the merican Medical ssociation 2A?, %o- A E233;F: 03306033@Ga!!a&he$, Thomas, Da(id Studde$t, a%d .e%d" Le(i%so%- BDis !osi%& Ha$m#u! Medi a! E$$o$s to Patie%ts-C .ew "ngland $ournal of Medicine ;1<, %o- 2< E233@F: 2@0;62@0?Ga!!a&he$, Thomas a%d Ri he$t Sui%%- B.hat to do 'ith the U%a%ti i)ated Out ome,C )a)e$ )$ese%tatio% at Medical Liability and (ealth Care Law Seminar EDRI > Ma$ h 233<, Phoe%i8, A$i5o%aF- htt):GG'''-'(mi - omG$is4ma%a&eme%tG a$e6)$o&$am-)h) Ea essed 01 Ma" 2303F-

Ga$de%t, Pau! +- a%d Susa% A- Ree(es- BEthi s Co%#!i ts i% Ru$a! Commu%ities: A!!o atio% o# S a$ e Resou$ es-C I% (andboo! for Rural (ealthcare "thics- edited b" .i!!iam ANe!so%, 0<=60A1- Ha%o(e$, NH: T$ustees o# Da$tmouth Co!!e&e, 233?htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG#u!!6boo4-)d# Ea essed 0= Ma" 2303FGe$a$di, Deb$a- BUsi%& Im)$o(isatio% to De(e!o) Co%#!i t Reso!utio% S4i!!s-C A(ai!ab!e o%!i%e at Mediate- om EO t- 2330F, htt):GG'''-mediate- omGGa$ti !esG&e$adi0- #m Ea essed 2? Ma" 2303F-

BCo%#!i t Ma%a&eme%t T$ai%i%& #o$ Hea!th Ca$e P$o#essio%a!s-C CResolution ES)$i%& 233;FBUsi%& Mediatio% Te h%i*ues to Ma%a&e Co%#!i t a%d C$eate Hea!th" .o$4 E%(i$o%me%ts,C C. Clinical 'ssues) dvanced Practice in cute and Critical Care 01, %o- 2 E233=F: 0A260?1-

001

BThe Cu!tu$e o# Hea!th a$e: Ho' P$o#essio%a! a%d O$&a%i5atio%a! Cu!tu$es Im)a t Co%#!i t Ma%a&eme%t-C Georgia State University Law Review 20 E2331F: A1@6A?3Conflict "ngagement Training for (ealth Professionals) Recommendations for Creating Conflict Competent *rgani&ations+ ,hile Paper for (ealthcare and %ispute Resolution Professionals+ Ha!# Moo% +a", CA: o- om Ea essed 01 Ma" 2303FEHCCO E2303F- Pub!ished o%!i%e at '''-eh

G$e%%", /ose)h- BC$u ia! Co%(e$satio%s: The Most Pote%t Fo$ e #o$ E!imi%ati%& Dis$u)ti(e +eha(io$-C

Physician "#ecutive $ournal of Medical Management ENo(GDe 233?F: ;36;;htt):GG%et-a )e-o$&GMembe$sO%!"G)eDou$%a!G233?GNo(De GG$e%%"M/ose)h-)d# Ea essed 2A Ma" 2303FGuada&%i%o, Ch$isto)he$- BMa!)$a ti e Mediatio% Poised to E8)a%d-C Physician3s .ews %igest EA)$i! 233=F- htt):GG'''-)h"si ia%s%e's- omG o(e$G=3=-htm! Ea essed 0? Ma" 2303FHa$(a$d Hos)ita!s- ,hen Things Go ,rong) Responding to dverse "vents+ Consensus Statement of the essed 01 Ma" 2303F(arvard (ospitals- +osto%, MA: Massa husetts Coa!itio% #o$ the P$e(e%tio% o# Medi a! E$$o$s, Ma$ h 233<- htt):GG'''-ma oa!itio%-o$&Gdo ume%tsG$es)o%di%&ToAd(e$seE(e%ts-)d# Ea

Het5!e$, Da!e, Li$&i%ia Mo$$iso%, Deb$a Ge$a$di, a%d Lo$$ai%e Sa% he5 Ha"es- BCu$i%& Co%#!i t: A )$es $i)tio% #o$ ADR i% hea!th a$e-C %ispute Resolution Maga&ine 00, %o- 0 EFa!! 233=F: 16@-

Hi 4so%, Ge$a!d, E!!e% C!a"to%, Pe%%" Githe%s, a%d F$a%4 S!oa%- BFa to$s that P$om)ted Fami!ies to Fi!e Medi a! Ma!)$a ti e C!aims Fo!!o'i%& Pe$i%ata! I%Du$ies-C $ournal of the merican Medical ssociation 2<@, %o- 03 E0??2F: 0;1?6<;I%stitute #o$ Sa#e Medi atio% P$a ti es- Survey on wor!place intimidation E233;Fhtt):GG'''-ism)-o$&GSu$(e"Gsu$(e"$esu!tsGSu$(e"3;00-as) Ea essed 2A Ma" 2303F-

Ise%ha$t, M"$a .a$$e%, a%d Mi hae! S)a%&!e- Collaborative pproaches to Resolving Conflict+ Thousa%d Oa4s, CA: Sa&e Pub!i atio%s, 2333/oh%so%, Ca$$ie- B+ad +!ood: Do to$ > Nu$se +eha(io$ P$ob!ems Im)a t Patie%t Ca$e-C Physician "#ecutive $ournal of Medical Management =No(GDe 233?F: <600htt):GG'''-oh%u$ses-o$&GCo%te%tGNa(i&atio%Me%uGResou$ esG.o$4)!a eLio!e% eRe)o$ti%&Fo$mG/o h%so%MCa$$ieM0-)d# Ea essed 2A Ma" 2303F-

/oi%t Commissio% o% A $editatio% o# Hea!th a$e O$&a%i5atio%s- Sentinel "vent lert HB9) 4ehaviors that Undermine a Culture of Safety- Issued /u!" 3?, 233Ahtt):GG'''-Doi%t ommissio%-o$&Gse%ti%e!e(e%tsGse%ti%e!e(e%ta!e$tGseaM=3-htm Ea essed 2A Ma" 2303FThe $oint Commission ccreditation Standards for (ospitals+ Oa4b$oo4 Te$$a e, IL: /oi%t Commissio% Resou$ es, 233?/oi%t Commissio% o% Hea!th Ca$e EState o# Li$&i%iaF- 0arious Responses to Medical "rror) Report %ocument .o+ :9;+ Ri hmo%d, LA: Commo%'ea!th o# Li$&i%ia, 233?/o%se%, A!be$t, Ma$4 Sie&!e$, a%d .i!!iam .i%s!ade- Clinical "thics) Practical pproach to %ecisions in Clinical Medicine- Eth ed+ Ne' Xo$4: M G$a'6Hi!!, 233<-

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Joh%, L-T- et a!- To "rr is (uman) 4uilding a Safer (ealth System+ .ashi%&to%, D-C-: Natio%a! A adem" P$ess, 2333J$ama%, Ste(e- BLi tim Com)e%satio% 'ithout Liti&atio%: The Le8i%&to% E8)e$ie% e-C Po'e$)oi%t )$ese%tatio% a(ai!ab!e at htt):GG'''-so$$"'o$4s-%etGe8 itedmi hi&a%-)htm! Ea essed 01 Ma" 2303F-

J$ama%, Ste(e a%d Gi%%" Hamm- HRis4 Ma%a&eme%t: E8t$eme Ho%est" Ma" +e the +est Po!i "-H nnals of 'nternal Medicine 0;0 EDe embe$ 0, 0???F: ?<;6@B+ad Mode!i%&-C (ealth ffairs 2<, %o- ; EMa"G/u%e 233@F: ?3;Le(i%so%, .e%d", Deb$a L- Rote$, /oh% P- Mu!!oo!", La!e$ie T- Du!!, a%d Ri ha$d M- F$a%4e!- BPh"si ia%6Patie%t Commu%i atio%: The Re!atio%shi) 'ith Ma!)$a ti e C!aims amo%& P$ima$" Ca$e Ph"si ia%s a%d Su$&eo%s-C $ournal of the merican Medical ssociation 2@@, %o- @ E0??@F: 11;611?-

Liebma%, Ca$o! a%d Ch$is Ste$% H"ma%- Medical "rror %isclosure- Mediation S!ills- and Malpractice Litigation) %emonstration Pro6ect in Pennsylvania E2331Fhtt):GG'''-)e't$usts-o$&Gou$M'o$4M$e)o$tMdetai!-as)8IidW2=;?A Ea essed 0? Ma" 2303FBMediati%& Medi a! Ma!)$a ti e La'suits: The Need #o$ P!ai%ti## a%d Ph"si ia% Pa$ti i)atio%-C

%ispute Resolution Maga&ine 0<, %o- ; ES)$i%& 2303F: <6?Ma8#ie!d, Da(id, et a!- BE8e uti(e Summa$"-C Silence 5ills) The Seven Crucial Conversations for (ealthcare E2331F- htt):GG'''-si!e% e4i!!s- omGUPDLGSi!e% eJi!!sE8e Summa$"-)d# Ea essed 2A Ma" 2303FMa5adoo$ia%, Ha$$"- BADR a%d Hea!th Ca$e: A% O(e$(ie'-C %ispute Resolution Maga&ine 0<, %o- ; ES)$i%& 2303F: =61Ma5o$, Jath!ee% M-, Ste(e% R- Simo%, Robe$t A- Xood, +$ia% C- Ma$ti%so%, Ma$&a$et /- Gu%te$, Geo$&e .- Reed, a%d /e$$" H- Gu$'it5- BHea!th P!a% Membe$s9 Lie's about Dis !osu$e o# Medi a! E$$o$s-C

nnals of 'nternal Medicine 0=3 E233=F: =3?6=0AM Do%%e!!, .i!!iam, a%d E!isabeth Gue%the$- BNa$$ati(e Re(ie': Do State La's Ma4e It Easie$ to Sa" BI9m So$$"IC-C nnals of 'nternal Medicine 0=? E233AF: A006A01Me!!o, Mi he!!e M- a%d Thomas H- Ga!!a&he$- BMa!)$a ti e Re#o$m6O))o$tu%ities #o$ Leade$shi) #o$ Hea!th Ca$e I%stitutio%s a%d Liabi!it" I%su$e$s-C .ew "ngland $ournal of Medicine ;<2, %o- 01 E2303F:0;1;60;1<Moo$e, Ch$isto)he$- The Mediation Process- 1rd ed+ ESa% F$a% is o: /osse"6+ass, 233;F: <=Mo$ath, /u!ie, a%d Te$$" Ha$t- BPa$t%e$i%& 'ith #ami!ies: dis !osu$e a%d t$ust-C Pa)e$ )$ese%ted at .ational Patient Safety 7oundation8 $C (* Patient Safety 'nitiative 2999) Spotlighting Strategies- Sharing Solutions EO tobe$ <, 23337 Chi a&o, ILFhtt):GG'''-%)s#-o$&Gdo'%!oadGMo$ath-)d# Ea essed 0= Ma" 2303FMo$$iso%, Li$&i%ia- B(eyo!a) The Shi#ti%& Sha)e o# Dis)ute Reso!utio% i% Hea!th Ca$e-C Georgia State University Law Review 20 E2331F: ?;06?<Ne!so%, .i!!iam A- BEthi a! u% e$tai%t" a%d sta## st$ess-C (ealthcare "#ecutive 2=, %o- = E233?F:;A6;?-

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Ne!so%, .i!!iam A- a%d Ja$e% E- S hi##e$de 4e$- BP$a ti a! St$ate&ies #o$ Add$essi%& a%d P$e(e%ti%& Ethi s Issues i% Ru$a! Setti%&s-C I% Ha%dboo4 #o$ Ru$a! Hea!th a$e Ethi s, edited b" .i!!iam A- Ne!so%, ;3=6;2;- Ha%o(e$, NH: T$ustees o# Da$tmouth Co!!e&e, 233?htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG#u!!6boo4-)d# Ea essed 0= Ma" 2303F-

Niemi$a, De%ise- BEthi s Co%#!i ts i% Ru$a! Commu%ities: Sha$ed De isio% Ma4i%&-C I% (andboo! for Rural (ealthcare "thics- edited b" .i!!iam A- Ne!so%, 0==60<;- Ha%o(e$, NH: T$ustees o# Da$tmouth Co!!e&e, 233?- htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG#u!!6boo4-)d# Ea essed 0= Ma" 2303FO9Co%%o$, A%%ette, Hi!a$" L!e'e!!"%6Thomas, a%d A%% +a$$" F!ood- BModi#"i%& U%'a$$a%ted La$iatio%s I% Hea!th Ca$e: Sha$ed De isio% Ma4i%& Usi%& Patie%t De isio% Aids-C (ealth ffairs .eb E8 !usi(e E@ O tobe$ 233=F: <;6@2htt):GG o%te%t-hea!tha##ai$s-o$&G &iG$e)$i%tGh!tha##-(a$-<;(0-)d# Ea essed 2A Ma" 2303FPi a$d, Che$"!, Pete$ +isho), Re%a Ram4a", a%d Nei! Sa$&e%t- The rt and Science of Mediation+ To$o%to: Emo%d Mo%t&ome$" Pub!i atio%s, Ltd, 233=Pu$ti!o, Ruth +- BThe Ethi a! Li#e o# Ru$a! Hea!th P$o#essio%a!s-C I% (andboo! for Rural (ealthcare "thics- edited b" .i!!iam A- Ne!so%, ==6<2- Ha%o(e$, NH: T$ustees o# Da$tmouth Co!!e&e, 233?- htt):GGdms-da$tmouth-eduG #mG$esou$ esGethi sG#u!!6boo4-)d# Ea essed 0= Ma" 2303FSui%%, Ri he$t- BCo)i 9s ;Rs P$o&$am: Re o&%i5e, Res)o%d to, a%d Reso!(e Patie%t I%Du$"-C Po'e$)oi%t )$ese%tatio%- htt):GG'''-so$$"'o$4s-%etG o)i -)htm! Ea essed 0= Ma" 2303F-

Ramsbotham, O!i(e$, Tom .oodhouse, Hu&h Mia!!- Contemporary Conflict Resolution, 2%d edMa!de%, MA: Po!it" P$ess, 2331Robbe%%o!t, /e%%i#e$ J- BA)o!o&ies a%d Le&a! Sett!eme%t: A% Em)i$i a! E8ami%atio%-C Michigan Law Review 032 E233;F: =<3610<Robso%, Rob, a%d Gi%%" Mo$$iso%- BThe Fi%a! ADR F$o%tie$: Co%#!i t Reso!utio% i% Hea!th a$e-C CResolution ES)$i%& 233;F: 23620Rose%stei%, A- H-, a%d M- OVDa%ie!- BDis$u)ti(e beha(io$ a%d !i%i a! out omes: Pe$ e)tio%s o# %u$ses a%d )h"si ia%s-C merican $ournal of .ursing 031, %o- 0 E2331F: 1=6<=Sa$a%, Je!!"- BThe U%i(e$sit" o# Mi hi&a% C!aims E8)e$ie% e: Dis !osu$e, Commu%i atio%, a%d Patie%t Sa#et"-C Po'e$)oi%t )$ese%tatio% at C PS C nnual Convening- pril 19- 29:9htt):GG'''- a)sa -o$&Gdo ume%tsGSa$a%-J-)d# Ea essed 0= Ma" 2303FS obie, A%d$ea, a%d D- Da(id Pe$saud- BPatie%t E%&a&eme%t i% Patie%t Sa#et": +a$$ie$s a%d Fa i!itato$s-C Patient Safety and /uality (ealthcare EMa$ hGA)$i! 2303Fhtt):GG'''-)s*h- omGma$ ha)$i!62303G=1=6)atie%t6e%&a&eme%t6i%6)atie%t6sa#et"6ba$$ie$s6 a%d6#a i!itato$s-htm! Ea essed 2A Ma" 2303 FSe)hu ha, Ja$e%, F!o"d Fo'!e$ /$-, a%d A!be$t Mu!!e" /$- BPo!i " Su))o$t #o$ Patie%t6Ce%te$ed Ca$e: The Need #o$ Measu$ab!e Im)$o(eme%ts i% De isio% Sua!it"-C (ealth ffairs .eb E8 !usi(e EO tobe$ @, 233=Fhtt):GG o%te%t-hea!tha##ai$s-o$&G &iG o%te%tGabst$a tGh!tha##-(a$-1=(0 Ea essed 2< Ma" 2303F-

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Studde$t, Da(id, Mi he!!e Me!!o, /e##$e" +u$%s, A%% Louise Puo)o!o, +e%Dami% Ga!)e$, Robe$t T$uo&, a%d T$o"a% +$e%%a%- BCo%#!i t i% the a$e o# )atie%ts 'ith )$o!o%&ed sta" i% the ICU: t")es, sou$ es, a%d )$edi to$s-C 'ntensive Care Medicine 2? E233;F:0=A?>0=?@Studde$t, Da(id, Mi he!!e Me!!o, Atu! Ga'a%de, T$o"e% +$e%%a%, a%d X- C!ai$e .a%&BDis !osu$e o# Medi a! I%Du$" to Patie%ts: A% Im)$obab!e Ris4 Ma%a&eme%t St$ate&"-C (ealth ffairs 2<, %o- 0 E/a%GFeb 233@F7 201622<Ta$$a%t, Ca$o!e A%%e- BCo)i 9s ;Rs P$o&$am: Re o&%i5e, Res)o%d to, a%d Reso!(e Patie%t I%Du$"-C Po'e$)oi%t )$ese%tatio% at C PS C nnual Convening, A)$i! ;3, 2303htt):GG'''- a)sa -o$&Gdo ume%tsGTa$$a%t-CA-)d#- See E)o'e$)oi%t a essed 0= Ma" 2303F-

Li% e%t, Cha$!es- BU%de$sta%di%& a%d $es)o%di%& to ad(e$se e(e%ts-C .ew "ngland $ournal of Medicine ;=A E233;F: 0310><Li% e%t, Cha$!es, Ma&&ie Xou%&, a%d A%&e!a Phi!!i)s- B.h" do )eo)!e sue do to$sI A stud" o# )atie%ts a%d $e!ati(es ta4i%& !e&a! a tio%-C The Lancet ;=; E0??=F:0<3?>0<0=.a4e#ie!d, /oh%, Ch$isti%e /o$m, a%d Che$ie R"a%- BO)e% Dis !osu$e: Detai!s Matte$-C (ealth ffairs 2<, %o- ; EMa"G/u%e 233@F: ?3;.a!4e$, T$a e"- BAd(o a " 'ith om)assio%: Do$oth" Ta$$a%t9s $o!e as hea!th a$e ombudsma%Gmediato$ )!a es he$ at the %e8us o# )atie%t6)$o(ide$ i%te$a tio%-C Managed (ealthcare "#ecutive E/u%e 0, 233<Fhtt):GGma%a&edhea!th a$ee8e uti(e-mode$%medi i%e- omGmheGLisio%a$iesGAd(o a "6'ith6 om)assio%6 Do$oth"6Ta$$a%ts6$o!e6as6GA$ti !eSta%da$dGA$ti !eGdetai!G;2??21 Ea essed 01 Ma" 2303F-

.ebe$, Da(id- BPo!! Resu!ts: Do to$s9 Dis$u)ti(e +eha(io$ Distu$bs Ph"si ia% Leade$s-C Physician "#ecutive ;3, %o- 1 ESe)t-6O t- 233=F: <60=.he!a%, Timoth", et a!- BE##e t o# a de isio% aid o% 4%o'!ed&e a%d t$eatme%t de isio% ma4i%& #o$ b$east a% e$ su$&e$": a $a%domi5ed t$ia!-C $ournal of the merican Medical ssociation 2?2, %o- = E/u!" 233=F: =;16=0.oD ies5a4, Dou&, /oh% +a%Da, a%d Ca$o!e Hou4- BThe So$$" .o$4sY Coa!itio%: Ma4i%& the Case #o$ Fu!! Dis !osu$e-C $oint Commission $ournal on /uality and Patient Safety ;2, %o- < E/u%e 233<F7 ;==6;=<P'eibe!, Rose, Go!dstei%, /oh% Ma%'a$i%&, a%d Me$idith Ma$4s- B.hat Sti 4s: Ho' Medi a! Reside%ts a%d A ademi Hea!th Ca$e Fa u!t" T$a%s#e$ Co%#!i t Reso!utio% T$ai%i%& #$om the .o$4sho) to the .o$4)!a e-C Conflict Resolution /uarterly 21, %o- ; ES)$i%& 233AF: ;206;13-

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