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CHAPTER 7
Principles of Evidence-Based Medicine

and Quality of Evidence

Daniel I. Steinberg, MD

INTRODUCTION
A BRIEF HISTORY

The March 1, 1981 issue of the Canadian Medical Association Journal included a
landmark article titled “How to read clinical journals: I. Why to read them and how to start
reading them critically.” Written by David Sackett, MD (1934–2015) of McMaster
University, it introduced a series of articles that highlighted the importance of critical
appraisal of the literature. Starting in 1993, a set of articles in the Journal of the American
Medical Association titled “Users’ guides to the medical literature” reprised and expanded
on the earlier series. These works, and other efforts by their authors, made critical
appraisal of the literature accessible to the masses and laid the groundwork for evidence-
based medicine (EBM).

Gordon Guyatt, MD, coined the term “evidence-based medicine” in the early 1990s,
while he served as the internal medicine residency program director at McMaster
University. Dr. Guyatt and colleagues had incorporated critical appraisal of the literature
into the residency program curriculum, and Dr. Guyatt wanted a term to describe and
advertise their efforts.

EBM caught on quickly over subsequent years as practicing physicians and training
programs embraced and taught its methods, with dissemination greatly fueled by the rise
of the Internet.

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ROLE OF CLINICAL JUDGMENT AND PATIENT PREFERENCES IN EBM

An early criticism of EBM, which some still harbor, was that it did not properly
acknowledge the importance of clinical judgment or patient preferences. In an updated
framework for evidence-based practice by R. Brian Haynes, P.J. Devereaux, and Gordon
Guyatt in 2002, evidence-based decisions are based on four cardinal elements: (1) the
research evidence, (2) the patient’s clinical state and circumstances, (3) the patient’s
preferences, and (4) the clinician’s judgment and expertise.

PRACTICE POINT

Clinical judgment and expertise are essential to the practice of EBM. These skills
facilitate optimal decision making by allowing the clinician to properly weigh the
research evidence in the context of the patient’s individual clinical circumstances and
preferences. Decisions should never be based on the evidence alone.

Practicing EBM may appear to be a straightforward affair with its methodical
approaches to clinical question construction and to searching and critically appraising the
literature. However, hospitalists should not confuse process with content, and they will
often find that EBM tends to highlight clinical uncertainty and gaps in the medical
literature. High-quality evidence does not exist to guide all clinical decisions, and
extrapolation from lower quality evidence is often necessary. Bayesian diagnostic decision
making often relies on clinical judgment to formulate pretest probabilities or to deal with
the uncertainty that accompanies inconclusive post-test probabilities. Learning to deal
with uncertainty is a core competency of EBM, which draws heavily on clinical judgment
and experience.

STAYING UP TO DATE WITH THE LITERATURE
PUSH INFORMATION RESOURCES

Few clinicians have the time to consistently read medical journals, identify relevant new
research and critically appraise new studies to determine if they should be incorporated
into one’s practice. “Push” information resources are resources that send content out to
their users on a regular basis. “Pull” information resources are databases that clinicians
search in order to answer a clinical question. Pull resources are discussed later in this
chapter. Table 7-1 lists selected high-quality push and pull information resources.

TABLE 7-1 High-Quality Push and Pull Resources

Push Resources Pull Resources
Resources that automatically send new,
high-quality evidence to users via e-mail or
RSS feed aggregator

Databases that are searched as needed to
answer clinical questions

ACP JournalWise ACP Journal Club
http://journalwise.acponline.org http://annals.org/journalclub.aspx

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BMJ Clinical Evidence BMJ Clinical Evidence
http://clinicalevidence.bmj.com http://clinicalevidence.bmj.com
DynaMed Cochrane Collaboration
https://www.dynamed.com http://www.cochrane.org
Evidence Updates DynaMed
https://plus.mcmaster.ca/evidenceupdates https://www.dynamed.com
NEJM Journal Watch NEJM Journal Watch
http://www.jwatch.org http://www.jwatch.org
PubMed (using an My NCBI account and
search strategies created by the user, see
text)
http://www.ncbi.nlm.nih.gov/pubmed

Practice Guidelines from professional
societies, eg, AHRQ National Guideline
Clearing House http://www.guideline.gov

  PubMed
  http://www.ncbi.nlm.nih.gov/pubmed

Trip Database
https://www.tripdatabase.com

McMaster PLUS (Premium Literature Service) continuously searches over 120 medical
journals and selects evidence for critical appraisal. Articles that pass the critical appraisal
process and are also rated as clinically relevant and newsworthy by their team of
reviewers are then transferred to the PLUS database. The PLUS database contributes
content to evidence-based summary resources such as EvidenceUpdates, ACP
JournalWise, DynaMed, and ClinicalEvidence. These resources all offer e-mail alerts to
users. ACP Journal Club and NEJM Journal Watch critically appraise and produce
synopses of high-quality evidence accompanied by expert commentary. PubMed, through
its free account service “My NCBI,” allows users to receive the results of literature search
strategies they either design or select (via the “Clinical Queries” feature) by e-mail on a
regular basis.

PRACTICE POINT

Hospitalists should strongly consider using an e-mail-based alerting service or RSS
(Rich Site Summary) feed aggregator from a high-quality evidence-based summary
push resource to effectively stay up to date on the literature.
Hospitalists can pair a virtual file cabinet with these resources to form an effective
information management system that will make evidence readily available at the point
of care.

KEEPING INFORMATION AT HAND: THE VIRTUAL FILE CABINET

Although the traditional way of storing articles for later reference is to use a physical file
cabinet, this approach has a number of disadvantages. File cabinets are not mobile, they

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cannot be quickly searched or updated, and determining how to best file something for
easy retrieval can be confusing. A clinician might ask himself/herself in frustration: “Did I
file that great article on pulmonary manifestations of HIV under ‘HIV,’ or ‘infectious
disease,’ or ‘pulmonary’?” They do not offer a way to electronically add content to them or
electronically share content with others, making them incompatible with modern
communication methods such as e-mail.

The virtual file cabinet (VFC) is an Internet cloud-based electronic document storage
system that synchronizes across multiple electronic devices (eg, smartphone, tablet,
laptop computer). A VFC is an effective way for hospitalists to electronically file articles
they receive from a push information resource as described above for easy retrieval at the
point of care. Box, Dropbox, Evernote, and Google Drive are some examples of the
commercial products that currently exist that can be used as a virtual file cabinet.
Products such as these also offer easy options for electronically sharing content with
others.

THE EBM PROCESS: ASKING AND ANSWERING CLINICAL QUESTIONS
Practicing EBM often involves asking and answering questions that arise during the care
of patients. There are four steps in this process: (1) asking a focused clinical question, (2)
searching the literature for the best available evidence, (3) critically appraising the
literature, and (4) applying the literature to an individual patient. This chapter explores the
basic principles of EBM as they relate to these four steps.

STEP 1: ASKING A FOCUSED CLINICAL QUESTION

Clinical questions fall into two general groups: background or foreground questions.
Background questions ask about general knowledge, pathophysiology, epidemiology, and
broad aspects of diagnosis and treatment. “What are the treatments for epilepsy?” is an
example of a background question. Junior learners often ask background questions, and
answers can often be found in textbooks. Foreground questions are more focused,
address specific clinical situations, and facilitate the delivery of the most up-to-date,
evidence-based care. Experienced clinicians ask foreground questions, with answers
residing more in the medical literature. Hospitalists should always aim to construct
focused foreground questions. These are further discussed below.

Most hospitalists would recognize the question, “Should patients with heart disease
receive regular vaccinations?” as one that is overly broad. Not all heart diseases are the
same, nor are all vaccinations, and the specific benefits patients might reap from
vaccination are not specified by the question. Clinical questions need to be focused in
order to be answerable. In addition to clinical questions about therapy, clinicians can ask
focused clinical questions about diagnostic tests, about the harm an intervention might
cause, about prognosis, or about differential diagnosis.

Clinical questions should be constructed using the “P-I-C-O” format. “P” stands for
“population” and describes the patient the question is about in proper detail. “I” stands for
“intervention” and refers to the therapy or diagnostic test in question. “C” stands for
“comparison” and describes either an alternative treatment or standard of care (for
questions about therapy) or the gold standard test (for questions about diagnostic tests).
“O” stands for “outcome,” which should be clinically important and patient-centered.
Surrogate markers of clinically important outcomes are acceptable.

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An example of a well-built clinical question about therapy is: “In patients admitted to
the hospital with non-ST elevation myocardial infarction (P), what is the effect of
influenza vaccination at discharge (I) as compared to no vaccination (C) on recurrent
acute coronary syndrome or mortality (O)?”

An example of a properly designed clinical question about a diagnostic test is: “In
patients presenting to the emergency department with suspected infection (P), how
accurate is a history of shaking chills (I), as compared a gold standard of blood cultures
(C) in diagnosing bacteremia (O)?”

When clinical questions do not perfectly fit into the P-I-C-O format, clinicians should
follow as many of the above principles as possible.

PRACTICE POINT

Clinical questions must be focused to be answerable. Hospitalists should use the
widely accepted “Population–Intervention–Comparison–Outcome” (P-I-C-O) format to
construct focused clinical questions.

STEP 2: SEARCHING THE LITERATURE

Pull information resources

With a properly constructed clinical question in hand, the hospitalist can now search the
literature to find the answer. The first step is to select an information resource that is
appropriate for the clinical question and the amount of time available. Databases that are
searched in an on-demand way in order to answer a clinical question are called pull
resources.

In many cases, and especially when time is limited, one should first consult a high-
quality summary pull resource. Summary resources that are frequently updated assess the
quality of the evidence presented and are user-friendly and preferable. Examples include
BMJ Clinical Evidence, ACP Journal Club, DynaMed, the Cochrane Collaboration, NEJM
Journal Watch, UpToDate, and practice guidelines from professional societies. All are
highly useful. Each has its strengths and weaknesses. UpToDate is fast to use,
comprehensive, and provides expert guidance in an easy to digest, narrative format, but it
is not as rigorously constructed as the others. ACP Journal Club provides excellent
summaries of highly selected literature deemed valid and relevant to clinical practice, but
as a result its database is not comprehensive. DynaMed is rigorously constructed and
presents a lot of primary data from clinical trials, often in an outline format. The Cochrane
Collaboration produces high-quality systematic reviews of the evidence. Practice
guidelines are excellent resources that offer clear recommendations, but their quality can
vary, update intervals can be long, and users must pay close attention to the level of
evidence and strength of recommendations in published practice guidelines.

If one has more time, or if a deeper dive is needed after consulting a summary
resource, the primary literature can be searched via PubMed (preferably using “Clinical
Queries” option for clinical questions) or Trip Database (preferably using “PICO search”
option for clinical questions). For certain questions, a content-specific resource can be
best. JAMAEvidence catalogs evidence on the accuracy of history and physical exam

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findings. The Cochrane Collaboration focuses on systematic reviews. No single resource is
perfect and clinicians should adopt a “toolbox” approach by becoming familiar with a few
resources.

PRACTICE POINT

Pull resources are databases that are searched in an on-demand way to answer a
clinical question. Pull resources have different and often complementary roles. None
are perfect, and hospitalists should adopt a “toolbox” approach in which they become
familiar with a few resources. The type of question and the amount of time available
to answer the question should help determine which resource the hospitalist consults.

THE HIERARCHY OF EVIDENCE

Hospitalists should know which types of clinical trials will best answer different types of
clinical questions, and which study designs will provide the most powerful results. The
randomized controlled trial (RCT) is the gold standard for determining the effect of a
therapeutic intervention.

Determining the accuracy of a diagnostic test requires a prospective design in which
the test is studied in the same clinical setting it will be used, and is compared against an
acceptable gold standard. The effect of a diagnostic test on clinical outcomes can be
determined by a randomized controlled trial, in which the test in question is treated as the
intervention and another diagnostic approach (preferably a gold standard if available) is
considered the comparison.

A systematic review is a summary of the evidence on a topic in which the literature
search and selection of evidence has been performed in a rigorous, transparent, and
reproducible way. The most valuable systematic reviews will also include a meta-analysis.
In a meta-analysis, the results of multiple similar types of studies (RCTs, observational
studies, or studies of diagnostic tests) are statistically combined to offer more powerful
results. What a meta-analysis gains in power, it can sometimes lose in applicability and
focus if too much clinical heterogeneity exists among the patients included from
individual studies. With that caveat, a high-quality systematic review that includes a meta-
analysis is considered to be the highest level of evidence. Table 7-2 describes the
hierarchy of evidence for different types of clinical questions.

TABLE 7-2 Hierarchy of Evidence for Different Types of Clinical Questions

Type of Clinical Question
Best Types of Articles (Listed in Decreasing Level of
Evidence)

Therapy or harm 1. Systematic review/meta-analysis of randomized controlled
trials

2. Randomized controlled trial
3. Cohort study
4. Case-control study
5. Case series

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6. Case reports
7. Expert opinion

Accuracy of a diagnostic
test

1. Systematic review/meta-analysis
2. Prospective comparison against gold standard conducted

in setting diagnostic test will be used in practice
Prognosis 1. Systematic review/meta-analysis

2. Prospective cohort study of a representative, homologous
patient group with appropriate follow-up and objective
outcomes.

3. Retrospective case-controlled study
Differential diagnosis of
a condition

1. Systematic review/meta-analysis
2. Prospective evaluation of a representative sample that

includes definitive diagnostic evaluation, performed in a
setting similar to actual practice

STEP 3: CRITICALLY APPRAISING THE LITERATURE

Although summary resources that appraise the medical literature have risen in quality and
are an essential resource for clinicians, they will not always provide the answer to a
clinical question. In addition, hospitalists may participate in discussions around particular
studies, attend “journal club” conferences, or teach junior learners about evidence-based
medicine. Hospitalists must have solid critical appraisal skills. The Users’ Guides to the
Medical Literature (McGraw-Hill, 2014) is the benchmark textbook for learning how to
practice EBM. It proposes an effective method for critical appraisal that has been widely
adopted. The principles and approach it endorses are discussed further in this chapter.

In appraising any type of study, three broad questions must be answered:

1. Are the results valid?
2. What are the results?
3. How can I apply the results to patient care?

The critical appraisal process asks these three questions of each type of study,
including those about therapy, diagnosis, harm, prognosis, and systematic reviews. Each
of the three major questions is answered through a subset of critical appraisal questions
that are specific to each study type. The critical appraisal questions help determine if a
study used proper methods to prevent bias, if the results are large enough to be
meaningful, and whether the results can be applied to a particular patient or population.

PRACTICE POINT

Critical appraisal focuses on answering three broad questions: Are the results valid?
What are the results? How can I apply the results to patient care? The Users’ Guides to
the Medical Literature offers a methodical approach to answering these questions for
studies about therapy, diagnosis, harm, and prognosis, and for systematic reviews.

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In recent years, a new type of evidence, the results of quality improvement studies, has
risen in prominence. As hospitalists often are involved in quality improvement efforts, they
should have a working knowledge of how to critically appraise this type of evidence. The
Users’ Guides to the Medical Literature offers further instruction in this area.

This chapter will illustrate the critical appraisal process through analysis of an article
about therapy, as randomized controlled trials and prospective cohort studies are among
the most common types of evidence encountered in practice. Table 7-3 outlines the
critical appraisal questions, which are discussed in detail below. Clinicians should refer to
the Users’ Guides to the Medical Literature for a complete list of critical appraisal
questions for different types of research studies.

TABLE 7-3 Critical Appraisal Questions for an Article About Therapy

Main Question Supplemental Questions
1. Is the study valid? a. Were patients randomized?

b. Was group allocation concealed?
c. Were patients in the study groups similar with respect

to prognostic variables?
d. To what extent was the study blinded?
e. Was follow-up complete?
f.  Were patients analyzed in the groups to which they

were first assigned (ie, intention to treat)?
g. Was the trial stopped early?

2. What are the results? a. How large was the treatment effect? (What were the
RRR and the ARR?)

b. How precise were the results? (What were the
confidence intervals?)

3. How can I apply the results
to patient care?

a. Were the study patients similar to my patients?
b. Were all clinically important outcomes considered?
c. Are the likely treatment benefits worth the potential

harm and costs? (eg, what is the number needed to
treat? What is the number needed to harm?)

Adapted from Guyatt G, et al., eds. Users’ Guides to the Medical Literature: A Manual for Evidence-
Based Clinical Practice, 3rd ed. New York, NY: McGraw-Hill Education; 2014.

CRITICAL APPRAISAL OF AN ARTICLE ABOUT THERAPY

To critically appraise an article about therapy, the clinician should answer the following set
of questions.

Are the results valid

Were patients randomized? Randomization will best ensure that the intervention and
control groups are equal at the start of the trial, except for the intervention being tested.
In observational studies, investigators must take special steps to ensure experimental
and comparison cohorts are evenly matched. Randomization does much of this
automatically.

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Was group allocation concealed? When allocation concealment is present, those
enrolling patients into the study during randomization are blinded to what group (ie,
intervention or control) the patients are being assigned. Without allocation
concealment, for example, a patient being enrolled but who is viewed as likely having a
bad outcome might be steered into the comparison group, potentially improving the
results in the intervention group.
Were patients in the study groups similar with respect to known prognostic
variables? This is necessary to isolate the effect of the intervention and minimize
confounders. Proper randomization will ensure this. In the absence of randomization,
clinicians should look to see that the intervention and comparison groups were
carefully matched so as to be equal for all possible confounders. This is often difficult
to do, which is why randomization is preferred.
To what extent was the study blinded? The term “double-blind” does not describe all
parties that should be blinded in an RCT. For maximum validity, multiple groups should
be blinded, including those selecting patients for randomization (ie, allocation
concealment), the patients, those administering the intervention, the data
collectors/analysts, and the outcome assessors. When patients or those administering
the intervention cannot be blinded (as in trials of certain surgeries or procedures),
allocation concealment, as well as blinding of data analysts and outcome assessors,
is essential.
Was the follow-up complete? Studies should track the outcomes of all participants.
Patients may be lost to follow-up if they suffer a negative outcome or find the
intervention too difficult to comply with. Both of these reasons would be highly relevant
to the results of a study.
Were patients analyzed in the groups to which they were first assigned (ie, intention
to treat)? The principle of “intention to treat” highlights that in a clinical trial, the
offering of an intervention to participants is being tested as much as the other effects
of the intervention. If for instance participants do not like the taste of a pill or find a
study protocol too hard to comply with and drop out of a trial or asked to be switched
to the other arm as a result, these consequences must be recorded as part of the
results of the study. Outcomes must be attributed to the group to which participants
were initially assigned. A trial that follows the intention to treat principle will give the
best estimate of what will happen if a therapy is offered to a population. In a “per
protocol analysis,” the study results represent only what happened to those who
actually accept the intervention and complete the trial. This type of analysis can
inform what effect a therapy would have if taken properly by a highly compliant
patient.
Was the trial stopped early? Follow-up must be an appropriate length for the outcome
measured. For example, 3 days might be an appropriate follow-up period for an
intervention to reduce acute pain, but it would likely be too short for an intervention
designed to reduce LDL cholesterol or to improve functional status. Randomized
controlled trials that are stopped early because of benefit may overestimate the effect
of an intervention. A large benefit observed early in a trial may be due chance, and may
be greater that what would be observed if the trial were allowed to run to completion.

What are the results

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How large was the treatment effect (ie, what were the relative risk reduction and
absolute risk reduction?)? Clinicians should consider results of a study using the absolute
risk reduction (ARR), where the ARR% = event rate in comparison group – event rate in
experimental group. The relative risk reduction (RRR) is calculated as RRR% = event rate in
comparison group – event rate in experimental group/event rate in comparison group. The
RRR allows one to determine the effect of a therapy on an individual patient according to
their baseline risk.

Consider the study by Sharma et al., published in the American Journal of
Gastroenterology in 2013, that randomized 120 hospitalized patients with cirrhosis and
overt hepatic encephalopathy to rifaximin versus placebo. In-hospital death occurred in
24% of the rifaximin group and in 49% of the placebo group. Here the ARR is 25% (49% –
24%) and the RRR is 51% (49% – 24%/49%).

Clinicians can use the RRR to estimate the effect a therapy will have on individual
patients they treat that may be more or less sick than the average patient in a study. For
example, if a patient is estimated to have a baseline risk of dying of 60%, rifaximin will
reduce this patient’s risk of dying to 30.6% (60% × 0.51). In this case the ARR will be
60%-30.6% = 29.4% which is higher than what the rifaximin group as a whole experienced
in the trial. In a similar way, lower baseline risk will result in lower absolute risk reduction.

PRACTICE POINT

A randomized controlled trial describes the average effect of an intervention across
the group of patients studied. The effect an intervention will have on any individual
patient can be determined by combining that patient’s baseline risk with the relative
risk reduction (RRR) reported in the trial. Clinicians can estimate their patient’s baseline
risk by comparing them to the clinical characteristics and comorbidities of patients in
a trial, and by using their clinical judgment and expertise.

HOW PRECISE WAS THE ESTIMATE OF THE TREATMENT EFFECT? (WHAT WERE THE
CONFIDENCE INTERVALS?)

Confidence intervals provide more information than P-values alone, giving an estimate of
the range of possible results. Some high-quality evidence-based summary resources, such
as ACP Journal Club, emphasize confidence intervals and the helpful picture they paint of
the results.

In the study of rifaximin described above, the RRR = 51% (95% CI, 20-71). In “plain
English,” this 95% confidence interval tells us that rifaximin most likely reduces in-hospital
death by 51% (the “point estimate”) but it may reduce in death by as little as 20%, or by as
much as 71%. There is a 95% chance that the true effect is between 20% and 71%, a 2.5%
chance the true effect is below 20%, and a 2.5% chance it is above 71%.

In order to determine whether a trial has found two therapies to be equivalent,
clinicians should examine the upper and lower limits of the 95% confidence interval. If
either would be clinically significant if true, the two therapies studied cannot be called
equivalent, and further research is needed. A 2014 study by Regimbeau et al. published in
the Journal of the American Medical Association found that in patients undergoing
cholecystectomy for acute calculous cholecystitis, postoperative antibiotics reduced

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infection by an absolute risk reduction of 1.9% (95% CI, –9.0-5.1, P < 0.05). The confidence
interval indicates that antibiotics most likely reduce infection by 1.9%, but may reduce
infection by as much as 5.1% (in which case most clinicians would prescribe them), or
may increase infection by as much as 9% (in which case most clinicians would not
prescribe them). In this study, the true effect of antibiotics on postoperative infection could
not be determined as they could be either beneficial or harmful, and further study is
needed. A common misinterpretation of these results, which could occur if the confidence
intervals are not noted, would be: “the P-value is greater than 0.05 so there is no difference
between antibiotics and placebo and the two are equivalent.”

Two factors affect the width of a confidence interval: the number of patients and the
frequency of the outcome in a study. In our example of the Regimbeau trial, further studies
that enroll larger numbers of patients or measure more postoperative infections could
result in a narrower confidence interval as well as a different point estimate.

PRACTICE POINT

Confidence intervals are preferable to P-values when considering the results of a
clinical trial, as they give more information about the range of possible results,
including the best and worst case scenarios.

How can I apply the results to patient care

Were the study patients similar to my patients? The more a patient meets the
inclusion criteria, and the less they meet the exclusion criteria, the more confidently the
results of a study can be applied to them. Clinicians should consider the setting of a
study as well as whether those who administered the intervention had specialized
expertise that is not available locally.
Were all clinically important outcomes considered? The “grandmother test” can help
determine if an outcome is clinically relevant. Outcomes that would be valued by the
average person (eg, someone’s grandmother) are clinically important; outcomes that
would not be valued are not clinically relevant and should not be measured by clinical
trials. For example, outcomes such as a reduction in pain, an increase in survival, or a
reduction hospital admission are likely to be meaningful to patients, while biochemical,
laboratory, or purely hemodynamic outcomes are not. An exception is when nonclinical
outcomes are established surrogate markers for clinically important outcomes.
Composite outcomes of clinical endpoints are valid, but if possible studies should
make clear how much each individual endpoint is driving the composite result.

PRACTICE POINT

Hospitalists should value studies that measure clinically important endpoints (or
surrogate markers of these) over those that measure physiologic or biochemical
endpoints.

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ARE THE LIKELY TREATMENT BENEFITS WORTH THE POTENTIAL HARM AND
COSTS? (WHAT IS THE NUMBER NEEDED TO TREAT? WHAT IS THE NUMBER NEEDED
TO HARM?)

The number needed to treat (NNT) describes how many patients must be treated with an
intervention to produce one positive outcome or prevent one negative outcome. The NNT
allows clinicians to compare the effects of different therapies, and is calculated as NNT =
100/ARR%. In the study by Sharma et al. discussed above, in-hospital death occurred in
24% of the rifaximin group and in 49% of the placebo group. Here the ARR is 25% (49% –
24%) and the NNT is 4 (100/25). In other words, we need to give four patients rifaximin to
prevent one patient from dying in the hospital.

In order to best inform risk/benefit discussions about a therapy, studies should
measure important adverse effects. The number needed to harm (NNH) describes how
many patients must be treated for one to experience a particular adverse effect. These two
numbers can be compared for an intervention and a particular adverse effect to determine
the net benefit or harm. In addition to the likelihood of adverse events and their morbidity,
the level of concern a patient has about particular side effects must be considered. Many
studies do not assess cost, and those that do often determine cost-effectiveness at the
population level, which is less relevant to the individual patient. The extent to which a
therapy is covered by insurance is highly relevant to patients and should always be
considered.

STEP 4: APPLYING THE LITERATURE TO AN INDIVIDUAL PATIENT

For the findings of a study to be useful in clinical care, the critical appraisal process must
yield a satisfactory answer to each of the three broad questions discussed above: a study
must be valid, it must report important results, and it must be applicable to the patient at
hand. If any of these three elements is missing, the study findings may not be appropriate
for implementation into practice.

When a study has used valid methods, has reported highly important results, and has
enrolled patients clearly similar to the patient in question, the hospitalist can confidently
apply its findings. But conducting clinical studies is often difficult work, and few studies
are perfect in every way. Clinicians need to learn which validity or applicability issues
represent fatal flaws, and which ones still allow the results of a study to be considered.
This is a skill that comes with experience.

The hospitalist must remember that best evidence-based decisions incorporate not
only the evidence, but also the individual clinical circumstances and preferences of
patients. In most cases, patient values and preferences are more important than the other
factors.

CONCLUSION
This chapter has focused on skills such as the construction of focused clinical questions
and how to search and critically appraise the literature. These skills are necessary but not
sufficient for the practice of EBM. The hospitalist’s knowledge of the patient is at the heart
of evidence-based practice. The right clinical questions cannot be asked unless the
hospitalist first has a clear understanding of the patient’s clinical issues, and the literature
cannot be applied to a patient without knowledge of their values and preferences.
Communication skills, history and physical examination skills, illness scripts, problem re

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CHAPTER 21
Principles and Models of Quality

Improvement: Plan-Do-Study-Act

Emmanuel S. King, MD, FHM

Jennifer S. Myers, MD, FHM

INTRODUCTION
Achieving better health outcomes for patients and populations requires a focus on
continuous quality improvement (QI). While physicians pride themselves on being subject
matter experts in their focused area of medical practice, such knowledge alone is
insufficient to produce fundamental changes in the delivery of health care. Physicians
who practice in complex hospital and health care systems must acquire another kind of
knowledge in order to develop and execute change.

W. Edwards Deming, an American statistician and professor who is widely credited
with improvement in manufacturing in the United States and Japan, has described this
knowledge as a “system of profound knowledge” (Figure 21-1). This knowledge is
composed of the following items: appreciation for a system, understanding variation,
building knowledge, and the human side of change. These concepts are just beginning to
be taught to health care professionals and are essential for anyone who wishes to
improve the health care delivery system.

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Figure 21-1 Deming’s System of Profound Knowledge. (Reproduced, with permission, from
Langley GJ, et al. The Improvement Guide: A Practical Approach to Enhancing
Organization Performance, 2nd ed. San Francisco, CA: Jossey-Bass; 2009.)

All hospitalists have witnessed changes that did not result in fundamental
improvements within their hospital systems: the computerized order set that was
successfully implemented but never revised based on prescribers’ feedback, the paper
checklist for medication reconciliation that never gets filled out, or the new rounding
system that worked for the first few weeks but then failed to become a standard part of
practice due to physician variation or lack of commitment. These are all examples of first-
order changes—changes that ultimately returned the system to the normal level of
performance. In quality improvement work, individuals must strive for second-order
changes, which are changes that truly alter the system and result in a higher level of
system performance. Such changes impact how work is done, produce visible, positive
differences in results relative to historical norms, and have a lasting impact. Although the
model for improvement described below may seem simple, it is actually quite demanding
when used properly; and the process is essential to both learning and ultimately changing
complex systems.

PLAN-DO-STUDY-ACT AS A TOOL FOR QUALITY IMPROVEMENT

The Plan-Do-Study-Act (PDSA) model is a commonly used method in quality
improvement. Shewart and Deming described the model many years ago when they
studied quality in other industries. This model first appeared in health care when Berwick
described how the tools could be applied using an iterative approach to change. Using a
“test-and-learn approach” in which a hypothesis is tested, retested, and refined, the PDSA
cycle allows for controlled change experiments on a small scale before expansion to a
larger system. The four repetitive steps of PDSA—plan, do, study, and act—are carried out
until fundamental improvement, which can be exponentially larger than the original
hypothesis, takes place (Figure 21-2).

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Figure 21-2 The Plan-Do-Study-Act Cycle. (Reproduced, with permission, from Langley GJ,
et al. The Improvement Guide: A Practical Approach to Enhancing Organization
Performance, 2nd ed. San Francisco, CA: Jossey-Bass; 2009.)

PRACTICE POINT

Use a “test-and-learn approach” to solve quality problems. The PDSA—plan, do, study,
and act—framework is one popular model to organize your approach to quality
improvement work.

PLAN

During the Plan phase, the team generates broad questions, hypotheses, and a data
collection plan. It is critically important during this period to define expectations and
assign tasks and accountability to every team member. In the planning phase of the PDSA
cycle, it is prudent to invest significant time and develop a well-framed question by
reviewing related research and local projects and defining meaningful process and
outcome measurements. Broad questions at the outset of a PDSA cycle can include “What
are we trying to accomplish?” and “What changes can we make that will result in an

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improvement?” The ideal data collection tool answers the question: “How will we know
that a change is an improvement?” It is also helpful for the team to generate predictions of
the answers to questions early on. This aids in framing the plan more completely, to
uncover underlying assumptions or biases before any testing, and to enhance learning in
the Study phase by providing a baseline point of comparison.

Teams new to QI frequently will struggle with the question, “How do we measure
improvement?” Defining discrete process measures is a good starting point when using
PDSA. Process measures are used to assess whether the cycle is being carried out as
planned. This is in contrast to outcome measures, which are used to track success or
failure and focus on the specific outcome that the team is trying to achieve.

DO

The Do phase in PDSA is a period of active implementation. It involves feedback on the
new process from end users and rigorous data collection. An overarching goal of this
phase is to capture and document not only compliance with the new process, but also
deviations, defects, or barriers in the process. There are always aspects of quality
improvement projects that do not go as planned, and flexibility and open-mindedness are
critical to maximize learning from improvement. The quality of the Do phase is intimately
related to the quality of the Plan phase. A pitfall for many novice QI teams is to give in to
the temptation to jump straight to implementing change without spending a significant
amount of time planning. A poorly conceptualized improvement plan, an absence of a
sound data collection model, or unclear accountabilities can have adverse effects on the
implementation or “do” phase of a new initiative.

STUDY

Analysis of available process and outcome metrics and a qualitative appraisal of the
process are the key activities in the Study phase. Time should be set aside to perform a
critical review of the data collected and compare it to historical data (when available) and
baseline predictions. Close attention should be paid to possible defects in any element of
the process, including the data collection plan. If such issues are uncovered, the team may
need to revise the initial data collection tools and overall plan. Thoughtful review of all
trials, even those that were clearly unsuccessful based on metrics, is a critical and
valuable process for the team. In fact, the “failures” in a PDSA cycle can yield
unanticipated and improved directions. As the Study phase progresses, time should be
spent considering if a follow-up PDSA cycle is planned and exactly what elements to
include in that cycle.

ACT

The final component in a PDSA cycle is Act. The team should convene for a feedback and
action planning session. Frontline workers in the system that is being changed should be
included for honest input. A team approach rather than a “top-down” approach facilitates
an open review of successes and failures. An action plan that encompasses lessons
learned in the first three steps should then be put into motion. During this stage decisions
are made about repeating certain test cycles after improvements are made or “spinning
off” new test cycles based on the original one.

RAPID CYCLE, CONTINUOUS, AND SEQUENTIAL PDSA

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In its most basic form, the PDSA model described above can be applied to change a single
process. However, teams in health care often confront problems that require multiple
changes, in parallel or succession, in order for improvement to happen. Caution is advised
when initiating several PDSA cycles simultaneously, especially if there are significantly
different data collection plans or if the team is inexperienced in QI methods. An alternative
is a sequential PDSA model in which one PDSA cycle feeds into the next. This approach,
in which teams continually change and refine their processes based on data evaluation
and feedback, is called “continuous quality improvement.” Experienced QI teams strive to
utilize this approach. Rapid cycle PDSA is a continuous QI process that lends itself well to
projects that are focused on relatively small-scale changes. It is typically used by
seasoned QI teams who are familiar with the PDSA model and who wish to implement
rapid change.

AN EXAMPLE OF PDSA IN ACTION
To illustrate the PDSA model for improvement, a real QI project is presented here from
start to finish. A hospitalist group sought to implement a new discharge planning toolkit
aimed at improving transitions in care through risk assessment at the time of hospital
admission. A QI team was formed with representatives from health care professionals
involved in the discharge planning process. While their ultimate goal was to reduce
unplanned readmissions, their first team goal involved creating a new process to
coordinate and request risk-specific interventions from other teams (eg, nurse educators,
pharmacists, a nurse for postdischarge follow-up phone calls) for patients deemed “high
risk for hospital re-admission or transition in care problems” by a screening tool. In
preparation for the project, the QI team also performed a stakeholder analysis, which is a
tool that QI teams can use to identify all of the individuals and groups with a “stake” in the
process being discussed.

CYCLE 1

PLAN

The initial PDSA cycle involved piloting a readmission risk screening tool. A weekly
meeting was convened that included representative users of the tool and assigned specific
responsibilities and tasks with due dates to each team member. At baseline, the biggest
barriers to overcome were the perception that the new tool was extra work, introducing a
paper-based tool in a largely electronic health care environment, and lack of a tight
infrastructure tying the requests to existing risk-specific interventions. Based on these
concerns, the team reduced the number of interventions on the initial tool. A data
collection plan was started and included both quantitative process metrics (eg,
compliance rates with the tool, frequency of risk factors identified on the tool) and
qualitative data from the users of the tool.

DO

The new tool was piloted for 2 weeks, during which time data was collected and feedback
was solicited from the frontline team.

STUDY

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After 2 weeks, the data showed that overall compliance with the tool was moderately high,
but that two risk factors, health literacy and depression, had unexpectedly low
percentages. On further inquiry, members of the team admitted that when they performed
the risk screen, they paused on those two questions and frequently left them blank,
concerned that it might take too much time during the admission process and frustrate
new users of the tool.

ACT

The team decided to make another edit to the tool before the second PDSA cycle. The
health literacy and depression screening questions were removed based on feedback, with
a plan to reintroduce them when the tool was more embedded in the hospital admission
workflow.

CYCLE 2
PLAN

The second PDSA cycle focused on follow-up data collection with the health literacy and
depression screening questions removed from the tool, to test the theory that this would
improve compliance. The data collection plan was to track overall compliance with the
tool for a 2-week period. In order to isolate any improvement as a result of this one small
change, no other changes were made during this time.

DO

The new version of the tool was implemented.

STUDY

Compliance rates significantly increased from moderately high to very high, and the risk
factor screening data remained unchanged. Qualitative feedback from frontline users was
that the risk screening process was more streamlined and acceptable.

ACT

A brief but successful cycle 2 ended with a plan to add an intervention checklist to the tool
in the next phase.

CYCLE 3

PLAN

The goal of cycle 3 was to associate risk-specific interventions (education, follow-up
phone calls, and social work interventions) with a patient’s individual risk factor profile. To
meet this goal, the team implemented a new version of the tool that included the risk-
specific intervention requests and tracked request type and volume. A 2-week cycle was
planned with continued weekly meetings during this time.

DO

The team implemented a tool that allowed for interventions to be requested at the time of
risk factor screening.

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STUDY

After 2 weeks, the data showed stable high compliance with the form, stable risk factor
data, but very low utilization of intervention requests. At feedback meetings, frontline
users stated that at the time of admission, they were not ready to place a request for an
intervention. They felt that intervention requests should be discussed in a multidisciplinary
team on a follow-up hospital day when more information was available.

ACT

Discharge planners on the team suggested that the intervention request process be
integrated into daily discharge planning rounds, during which the entire patient care team
(physician, nurse practitioner, registered nurse, discharge planners, patient service
representative, and social worker) discussed each patient on the service. A nurse
practitioner and patient service representative drafted paper forms that could be used to
communicate requests for each of the interventions to the appropriate personnel and to
document completion of the task. The next phase would trial this new process.

CYCLE 4
PLAN

Cycle 4 was focused on implementing and studying the new discharge rounds process to
request risk-specific interventions. The frequency of intervention requests in each category
was added to the existing process metrics. Since this was a more substantial change than
before and involved more than just one team of frontline users, a 4-week cycle duration
was chosen.

DO

Clinicians continued to screen patients using the risk screening tool, intervention request
forms were kept on hand during discharge rounds, and the patient service representative
and discharge planners prompted the teams to request interventions based on patient risk
factors. The requests were forwarded to the appropriate personnel (registered nurse,
pharmacist, nurse educator), who then documented completion of the intervention on the
form.

STUDY

Compliance rates and risk factor data remained steady, but there was a significant
increase in intervention requests in all categories. However, documentation of completion
of the intervention was low. It was determined that the documentation requirements were
unfamiliar to the intervention teams, which was an oversight.

ACT

For the next cycle further improvements in documentation of intervention completion and
a reintroduction of the health literacy and depression screening questions was planned.

LESSONS LEARNED

This example illustrates several important points for successful use of the PDSA model.
First, the engagement and involvement of the end users of new QI tools and processes is

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critical to the success of any improvement project. These users are experts in the process
who often know what should be tested next, and perfect champions when changes are
disseminated on a larger scale. While it may be impossible to address or fix every problem
that they identify, hearing their input, implementing changes based on their suggestions,
and giving praise for their involvement and patience is an important skill for leaders of QI.
Second, flexibility and creative thinking, skills that are used frequently in clinical care, are
also essential in QI. In the case study, several barriers were identified such as: concerns
about paper forms, perception that certain risk factors would halt the risk screening
process, and lack of infrastructure around the systematic documentation of interventions.
As these barriers became apparent, the team remained flexible and changed a part of the
new process without compromising the integrity and team goals of the project.

PRACTICE POINT
Critical to the success of any quality improvement project:

Performing a stakeholder analysis to help identify all individuals and teams that have
a “stake” in the quality problem that is being addressed.

Engagement and involvement of the “end” users of new QI tools and processes.
Small tests of change that include data collection followed by data analysis and
decisions on how to proceed.

ALTERNATIVE MODELS OF QUALITY IMPROVEMENT

In addition to the PDSA model described above, there are other frameworks that have been
used to design and execute quality improvement projects. Adopting one specific
framework (as opposed to adopting several) allows an organization to learn a common
language and approach to improvement. Six Sigma and Lean are two common
frameworks that will be briefly described.

Six Sigma was developed by Motorola in the mid-1980s and is focused on reducing
variations in a process. Six Sigma is a popular performance improvement methodology
which uses a five-phase approach to problem solving, called DMAIC (Define, Measure,
Analyze, Improve, and Control). This framework guides users to define their QI goals,
measure the current process, analyze root causes of the quality problem, improve the
process on the basis of the previous steps, and finally control the process to ensure that
variances are corrected before they result in defects and the new process becomes
standard work.

Lean manufacturing (or just “Lean”) was adapted from the Toyota Production Systems
and is focused on continuously reducing waste in operations and enhancing the value
proposition to customers. The Lean approach is based on a few key principles: defining
the problem from the customer perspective, identifying the activities required to provide
the customer with a product or service, producing the products or services only when
needed by customers, and pursuing perfection in the process.

CONCLUSION

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Plan-Do-Study-Act has remained a fundamental tool for continuous quality improvement.
Once comfortable applying this iterative app

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ospitalists assume patients understand their presence at the bedside. More effort in
explaining the role of the hospitalist as the internal medicine physician or family medicine
physician who is responsible for patient care while the patient is in the hospital is
essential. Once patients understand that the hospitalist is the physician assuming
responsibility for everything from admission to discharge, including making patient
rounds and ordering all needed tests and procedures it helps them understand why the
hospitalist is caring for them. An important component of the dialog is that the patient
understands that their primary care provider (PCP) is informed of their progress and
resumes care for the patient postdischarge.

With the Centers for Medicare and Medicaid Services moving from a fee-for-service to
a fee-for-value payor, the hospitalist takes on an important role in coordination of care
with a focus on population health. Today there is a deeper understanding of the
importance of managing population health to drive the health of the community that a
health system serves. Central to this movement is the need for robust measurement
systems that enable us to concentrate on the outcomes of a population instead of
individual silos within the delivery system. Hospitalists are in unique position to deliver on
the Institute of Medicine’s “Triple Aim,” targeting better health for the population, better
quality and patient experience of care while lowering the cost of care. With more than 50%
of all health care spending generated from the acute care admission through the 90-day
postacute period, the hospitalists team is ideally suited to manage care from the
emergency department (ED) to postacute care.

The highest performing hospitalist groups can bring value to the populations they
serve through predictable outcomes. Hospitals would benefit from bringing hospitalists
into the discussion about population health and overall performance improvement in
acute and postacute care management. Many hospital Accountable Care Organizations
(ACOs) have not focused on a postacute care strategy, where much of the variability and
costs occur in the 90-day period following discharge nor have they recognized the role
hospitalists can play in tackling this issue. Improving performance across the acute
episode of care is best achieved with a comprehensive hospitalist infrastructure that
incorporates physician development, leadership support and incorporation of evidence-
based data to measure performance and drive continuous quality improvement. High-
performing hospitalist teams that hardwire these elements into their practice will drive
performance improvements and grow their practice.

This chapter explores the specific components essential to building, growing, and
managing a thriving hospitalist practice with staying power in light of the new fee-for-
value environment.

STRATEGIC PLANNING
It is important to have a strategic plan for the practice around growth and the types of
hospitals and programs best aligned with agreed upon goals and objectives. For example,
strategic planning may require not aligning with all groups requesting support of the
hospitalist team. If a group does not fit your strategic profile or geography, it may be best
to decline the opportunity to manage a program. Depending on the goals of the practice,
certain approaches may not promote patient satisfaction or continuity of care goals. For

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example, when a hospital simply wants your team to cover admissions during the “off
hours” that residents are not covering patients and then transfer patients back to residents
or surgeons during “peak hours”. These practices work against the goals of improving the
patient experience of care and can erode coordination of care. Obstacles of geographic
distance requiring a day of travel of the core management team present an additional
burden that may make it best to pass up the opportunity to service a hospital if key
management team members cannot be present on a regular basis. Each hospitalist group
should critically evaluate whether the growth in a new hospital makes sense based on the
values and goals of the hospitalist practice, in addition to the hospital seeking hospitalist
services.

STRATEGIC PLANNING PROCESS
Before starting a hospitalist practice, determine factors that predict the success or failure.
Identify the business and financial motivators required to build, expand, and manage a
hospitalist service. These factors should incorporate the needs of the hospital and
community the practice it serves.

PRACTICE POINT
The hospitalist practice must start with a strategic planning process.

What are the goals of the practice?
What are the needs of the hospital?
How feasible is it to recruit to the location?
What outcomes and metrics are expected by the hospital?
Can the practice commit to the hospital’s performance expectations?

In order to build a hospitalist practice, hospital leaders should:

Define the scope of services.
Articulate the vision, mission, values, and key value drivers (KVDs) of the practice.
Establish the employment model and compensation strategy to drive performance.
Determine the size and cost of the program.

After a program is up and running, successful practices may be faced with
unprecedented growth. Hospital leaders will need to:

Set expectations and priorities for growth.
Define key stakeholders.
Plan for growth.
Assess the evolving needs of the service, such as using advance practitioner
providers (NPs and PAs).
Determine the skills in a hospitalist practice and the need for additional provider
training.

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Determine whether the requested skill set of providers by hospital administration
coincides with the ability to recruit to the program.
Reassess the compensation model as the needs of the service change. For example,
hospitalists with the skills to provide ICU procedures will cost more per shift than
general medical hospitalists.

From the building stage forward, there is a constant need for outstanding
management to ensure a hospitalist practice thrives by using the steps provided in the
following tables: (Tables 23-1, 23-2, and 23-3)

TABLE 23-1 Building a Hospitalist Program: Key Factors to Consider

Characteristics Examples
Recruiting • Is the location conducive to recruiting hospitalists?

Do they need to recruit a leader?
Compensation plan • What is the market rate?
Number of encounters/physician • What is the number of patients at 7 AM census?

• What total number of patient encounters will
physicians manage per day?

• What is the acuity of patients in the mix?
Schedule • Is a traditional block schedule feasible?

• Do you offer additional vacation days?
Management support • What local support is required?

• What regional support is required?
Tools to support communications,
charge capture, scheduling,
metrics

• How will hospitalists record charges?
• Is there a convenient method to communicate to

PCPs?
• How will you demonstrate improvement in

performance?
• How will the group demonstrate quality?

Clinical processes development • What best practices does the group adopt?
• How do the processes impact care?

TABLE 23-2 Growing a Hospitalist Program: Core Values and Goals

Characteristics Examples
Quality • Measure length of stay

• Measure readmissions rate
• Measure CMS core measures
• Measure time of discharge
• Measure case mix index

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Satisfaction • Measure patient satisfaction
• Measure nursing satisfaction
• Measure PCP satisfaction
• Measure specialist satisfaction
• Measure administrative staff satisfaction

Efficiency • Determine how to improve admission and discharge
efficiency

Innovation • What tools can be developed to support the team’s core
values?

Teamwork • Determine how the team interacts with monthly and
quarterly meetings.

• How do you organize in teams?
• What is the role of advance practice providers?

Leadership • Is there a leadership development training path?
• Is there a medical director or chief hospitalist on the site?
• Are there regional leaders for clinical and business

operations?
Financial • Does the group charge a fee for services?

• What are the overhead costs to manage the practice?
• Is there a clear return on investment for the hospital to retain

services of the group?
Integrity • What guidance does the team provide to the physicians in

the group?
• How do we manage the impact of actions, values, methods,

measures, principles, expectations, and outcomes of the
team?

• What criteria are used to assess integrity of candidates?
Research • Is the group involved in research?

• Is there support for data collection and analysis?
• What funding is available to the group to support research?

PCP satisfaction • How does the group measure PCP satisfaction?
• Does the group reach out to the PCPs?
• How does the group track referrals from PCPs?

Nursing satisfaction • How does the group measure nursing satisfaction?
• Does the group interface with nursing?
• How does the group track nursing impact on outcomes?

Specialist satisfaction • How does the group measure specialist satisfaction?
• Does the group reach out to the specialist?
• How does the group track referrals from specialists?

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TABLE 23-3 Managing a Hospitalist Program: Key Strategies for Effective Management

Characteristics Examples
Recruiting • How does the group identify new hires?

• Does the group use a recruiting agency?
Overhead • What percentage of revenue is allocated to support

programs (overhead)?
• Do costs incorporate utilization of advance practice

professionals, nurses, support staff, and locum tenens?
Training • What allocation of resources does the group have for CME

training?
• How are new group members trained?
• How are leaders mentored?

Growth • Does the group want to expand?
• Is the group capable of taking on additional patients at the

primary site?
Service lines • Does the group focus on acute care contracts with

traditional hospitalists?
• Does the group provide intensivists services?
• Are there other service lines to consider: surgicalists,

laborists, academic hospitalists, post-acute care/transitional
care?

Improvement strategies • Where is the group’s focus on quality? Efficiency?
Satisfaction?

Define the right leadership and structure.
Create an ownership mentality.
Setting up the right processes.
Tracking and reporting actionable data.
Provider education focused on leadership excellence and performance management.
Promoting outreach to the physician community and facilitating transitions of care.

BUILDING A HOSPITALIST PRACTICE
Building a hospitalist practice starts with defining the prospective hospital partner’s needs
for a hospitalist program. In many community hospitals, a hospitalist program is created
to care for the unassigned patient population. But even the definition of an unassigned
patient is subject to much interpretation. For example, at many hospitals in the Puget
Sound region of Washington State, an unassigned patient is any patient showing up in the
emergency department and requiring admission who does not have a primary care doctor
that admits patients at the hospital. In contrast, in Orlando, Florida, an unassigned patient
is only defined as a patient who has no primary care doctor. In Orlando, if a patient has a

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primary care provider but that doctor does not have admitting privileges, it is standard
practice to call the primary care provider to identify who will care for the patient in the
hospital.

PRACTICE POINT
The needs assessment, from the perspective of the hospital might include:

PCP and/or surgical dissatisfaction
Admission and management of unassigned patients
Admission and management of overflow patients due to American College of
Graduate Medical Education (ACGME) work hour restrictions
High inpatient census and long average length of stay (ALOS)
Low reported performance measures
External regulation (rapid response teams, code teams, etc)

In addition to covering the unassigned patient population, many hospitalist services
cover those primary care providers who do not want the responsibility of admitting their
own patients. There are two main forms of coverage relationships: coverage
arrangements for 24 hours per day, 7 days per week; and coverage which is more like a
house staff model in which the hospitalist admits the patients but then turns the care back
over to the PCP the next day. These latter models continue to decline in numbers because
of difficulty with recruitment of high-quality providers motivated to build a meaningful
career with a resident-type model.

Hospitalist programs may also be created to manage medical specialty and surgical
patients, usually after establishment of the initial hospitalist program.

It is essential to determine which patients the hospitalist group will manage, the scope
of services, and whether additional training for some of the program members will be
required. According to the Medical Group Management Association and Society of
Hospital Medicine 2014 State of Hospital Medicine Report (n = 4867) (see Figure 23-1).

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Figure 23-1 Specialty composition of survey respondents. (Source: 2014 State of Hospital
Medicine Report. Reprinted with permission from the Society of Hospital Medicine.)

Eighty-three percent of practicing hospitalists are trained in internal medicine, 10% in
family medicine, 7% in pediatrics, and 1% in med/peds. Data from the American Medical
Group Association (n = 3700) report hospitalist training to represent 89% internal
medicine, 6% family medicine, 5% pediatrics (did not ask about med/peds). When looking
at the combined MGMA (community hospitals) and AMGA (academic hospitals) data, the
distribution represents training spanning 80% internal medicine, 8.5% family medicine,
10% peds and 1% med/peds. The general trend represents and increased in hospitalists
with family medicine training.

In most community hospitals today, hospitalists manage ICU patients. While there are
just over 10,000 intensivist physicians in the United States, there is an increasing demand
for critical care services to serve the aging population and extended life expectancy.
Although the number of critical care physicians in training has been growing, it will be
difficult to meet the patient demand with the rapidly aging population. Research indicates
the increased demand creates a shortfall of intensivists equal to 35% by 2020, requiring
hospitalists to step in to fill some of the demand. In general, the larger the hospital the less
ICU medicine a hospitalist performs. Many hospitals have mandatory ICU consults after a
set number of days or hours in the ICU or they provide specific guidelines on managing
ventilated patients. The most popular model may be a hybrid arrangement in which
access to a critical care physician occurs during the day and for emergencies but in-house
at night. In such cases the hospitalist commonly does the work around admissions and
daily visits with a consult and a follow-up visit by the pulmonary critical care physicians.

With the labor shortage being even more severe for critical care, hybrid models, along
with the advent of telemedicine, are likely to take on even more ICU coverage
responsibilities in the future. In general, leapfrog compliance guidelines drive a dedicated
intensivist model, typically mandated in regional and tertiary hospitals.

“Code coverage” also defines the scope of the hospitalist practice. Many hospitals
provide a separate code team, made up of the emergency medicine physician or in-house

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intensivist plus respiratory therapy, nurses, technicians, and pharmacists. Increasingly,
hospitalists are being asked to partake in responding to the code process and arranging
patient transfers to the ICU. In general, emergency physicians have more training and
chances to keep their skills sharp around the procedures of a code, including intubation,
starting central lines, and transvenous pacing. Typically, while an emergency medicine
physician may respond first, a hospitalist with advanced cardiac life support training
assumes leadership of the code.

Whether the hospitalist scheduled for the night shift is actually in the hospital or at
home on call for emergencies also defines the scope of practice. Hospital-employed and
hospital-contracted models tend to have in-house coverage while physicians who are part
of a private fee-for-service group without a hospital contract tend to be available as an on-
call physician available from home. Variables that impact the decision beyond economics
include the volume of cross-coverage patients, the number of admissions per night,
coexisting resident coverage, and the response time of the physician, if on call from home.

DEFINING THE TYPE OF EMPLOYMENT MODEL

There are several common employment models for hospitalist practices: employed by a
private practice, by a hospital, by a multispecialty group, by a health plan/HMO, or a
multisite or national practice. Among the multisite or national practice subgroups there are
staffing solutions that specialize in emergency medicine, anesthesia, and a host of other
physician specialists. Some of these multisite specialty practices will hire hospitalists who
work as independent contractors alongside the specialist. Among the national hospitalist
groups there is a wide spectrum of employment arrangements ranging from those offering
ownership and partnership to those that operate solely with independent contractors.

DEFINING THE VISION, MISSION, VALUES, AND KEY VALUE DRIVERS OF YOUR
PRACTICE

It is critically important to define the vision, mission and values of the practice from its
inception. The leaders and hospitalists should take this task seriously. Schedule time to
discuss and debate what is important to the group and leadership. The process of
constructing your program’s mission and vision statement should not be taken lightly. This
process can take weeks to develop. Start by establishing dedicated time and secure an
environment that is conducive to having uninterrupted, frank discussions. Enlist the input
of all team members.

A mission statement explains the overall purpose of the hospitalist practice. The
mission statement articulates what the organization does right now, in the most general
sense. In this way, the mission also sets parameters for what the organization, through
omission, does not do. Example of a mission statement: “The Hospitalist Group of Hilltop
builds healthy relationships between St. John’s Hospital and primary care providers in the
community through public education and direct assistance services.”

By comparison, the vision statement articulates the future of the organization and the
community that it serves. The vision statement, when compared with the current reality of
the organization or the community, implies the work still needs to be accomplished. In this
way, it lends credibility and motivation to the mission statement. Example of a vision
statement: “The Hospitalist Group envisions a group practice that drives improvements in
patient outcomes including evidence that reflects our value to hospitals in our
community.”

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On a yearly basis the practice should define key value drivers that articulate the focus
of the organization and those areas that require organizational focus in order for the
business to grow. Key value drivers (KVDs) should be set by the leaders with input from
the entire team. KVDs must be easy to remember, measurable, and achievable. The
behaviors that support the key values should also be clearly defined. In doing so, those in
the practice will have a clear understanding of expectations even prior to joining the
practice. These behaviors should be reinforced through the compensation and promotion
practices of the group to make the practice values meaningful and alive on a daily basis.
Typically teams evaluate progress on KVDs monthly or quarterly.

ESTABLISHING METRICS AND SETTING NEW GOALS FOR PERFORMANCE AND
OUTCOMES

Standard outcome metrics including average length of stay, core measures, case mix
index, cost per case, and discharge efficiency are expected by hospital administration from
the hospitalist group. It is essential to meet with the hospital and obtain agreement on
which initiatives the hospitalist team will focus. Establish a data collection and reporting
mechanism and the frequency of assessments. Practice metrics that are becoming
increasingly important to hospitals include the Healthcare Cost and Utilization Project
(called “H-CUP”). HCUP is a set of health care databases, software tools, and products
developed through a Federal-State-Industry partnership and sponsored by the Agency for
Healthcare Research and Quality. Using the HCUP databases collates data collection from
State organizations, hospital associations, private data organizations, and the Federal
government creating a national data benchmark.

HCUP databases include the largest collection of longitudinal hospital care data in the
United States, with all-payer, encounter-level information going back to 1988. These
databases enable evaluation of cost and quality of health services, medical practice
patterns, access to health care, and outcomes of treatments at the national, State, and
local levels.

In addition to the standard outcome measures and HCUP data, it is useful to track and
report other practice related trends, including PCP referral volume and referral patterns,
patient satisfaction, physician recruiting efficiency, physician retention and 30-day same
diagnosis readmission rates (Figure 23-2).

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Figure 23-2 A dashboard of standard outcome metrics organized by volume of patients,
quality, utilization, satisfaction trend, and market data indicators including evaluating
performance to HCUP data.

MARKETING YOUR HOSPITALIST SERVICES

The best marketing generates word-of-mouth public relations based on how satisfied your
patients are as well as the nursing and other hospital staff. An effective campaign
requires all hospitalists on the team to be fully engaged with the practice’s vision, mission
and values.

In addition to the passive marketing that comes from word-of-mouth marketing, it is
important to develop a marketing plan. A typical marketing plan for a practice includes
initiatives that drive patient satisfaction to generating awareness in the community
through PCP outreach. Create a budget that supports the plan.

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PRACTICE POINT
Your marketing plan should include segments that target the following areas:

Identify your target markets: Decide which target markets you want to canvas. You can
either target referrals in specific geographic areas or by targeting outreach to
specialists.
Develop a public relations plan: Launch a new program with press releases, open
house events, or broadcast the addition to new physicians through flyers or direct mail
campaigns.
Create a promotion/awareness plan: You can develop practice-branded written articles
on a variety of topics that convey answers to patients’ questions using topics such as
What is a Hospitalist? or Improving Patient’s Health Literacy. Use these in a mailing to
your community or have the hospital place your articles in their newsletter. Develop a
social media campaign to highlight the culture of your practice to support recruiting
and growth efforts.
Develop patient satisfaction tools: Create large, oversized business cards with photos
of physicians, hospitalist brochures with photos of engaged, friendly physicians;
consider web-based information to share with patients.
Create recruiting advertisements for physicians: Provide your recruiters with materials
about the opportunity or special information about the location and hospital. Place
them in hospitalist journals as print advertisements and classified ads.
Conduct market research: Conduct market research in your local area to be sure you
know what the local market is paying for hospitalists and places they practice and who
might be interested in joining your practice in the area.
Profile your team: Utilize a website and direct mail with photography of your team or
host an open house or educational event.
Develop a social media strategy: Share the culture of your team to encourage
prospective referrals for service and for recruiting.

DESIGNING THE MODEL

It is essential to determine the size of the practice needed. The volume of patients who will
be seen on a daily, nightly, and monthly basis determines the size of the practice. Next,
assess the number of physicians required to meet the needs of the practice based on that
estimated patient volume. The number of physicians depends on what is considered an
acceptable workload of patients to manage per day, per night, and per month. To
determine the number of patients, define the average number of admissions per day. If the
emergency department uses a tracking tool, review the data to project the number of
unassigned patients based on historical data. In many hospitals, these data are not
accessible prior to initiating a program. Historically, the ward clerks simply entered the
admitting physician’s name in the hospital information system without mention of the fact
that the patient did not have a primary care physician. It is essential to have a way to track
the types of patients by referral type (eg, by PCP, unassigned, or consultations) when the
hospitalist program begins operation.

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In addition to determining the volume of unassigned patients, estimate the number of
PCPs interested in turning over care. The only risk of double counting is if no hospitalist
program existed before a new program starting up. Typically, in that scenario, the primary
care provider was also likely cover unassigned patients.

After determining the number of admissions per year, divide the admissions by 365
days per year to obtain a rough estimate of the number of physicians required. Then take
the average length of stay for the patients and add 1 extra for the day of discharge. Take
this number and multiply it by the number of admissions per day to determine the 7:00 AM
census. For example, if there are five admissions per day with an average 4-day length of
stay, the 7:00 AM census would be calculated as 5 × (4 ALOS + 1) = 25 patients at 7:00 AM.
With the 7:00 AM census determined, calculate the number of the physicians per morning
required for the hospitalist program.

There is much debate over the most appropriate census for the physician who begins
rounding at 7:00 AM. In general, based on a typical mix of a few ICU patients and the
balance of the load being medical patients, a hospitalist can manage 15 patients safely
and efficiently. This number varies considerably due to the different agendas, acuity of
patients, concomitant responsibilities such as rapid response teams, code teams,
teaching, and goals of practices. To achieve the objectives of early discharge, multiple
visits a day and a considerable amount of committee involvement, hospitalists can
maintain a census in the range of 14 to 15 patients. If the goal is productivity, and in some
cases the use of advanced practitioner providers (APPs), the volume per hospitalist may
be as high as 20 patients per day. Some practices define the census as the number of
encounters per day, which include new admissions as well as discharges.

In a pure productivity-driven private practice model, the night shifts are often covered
from home (eg, only coming back to the hospital for emergencies). This typically also
means that the day-shift doctors might share night call, even after working all day. In
many practices today, the night shift is covered by a separate physician, a nocturnist, due
to the volume of admissions at night and the volume of cross-cover work needed.

In general, the billing revenue of a nocturnist hospitalist is lower than a day-shift
hospitalist.

A highly prevalent hospital-employed and national group practice model includes a
schedule in which the hospitalist physician is on duty for 12 hours, 7 days a week and the
following week the physicians is off for 7 days. There are also hybrid arrangements in
which the physician works about the same total number of hours per month but with
shorter periods of time on duty. In such a model, a 7:00 AM census of 25 to 30 patients
would likely have six full-time physicians. In contrast, a private group model may take
every fourth night of call from home, which could be managed with four full-time
physicians on the team. The marketplace supply and demand for physicians and goals of
various clients (eg, a hospital, HMO, or payor) often dictates the type of model required.

DETERMINING THE COST AND DIRECT COST OF THE HOSPITALIST PROGRAM

Calculating the cost of a hospitalist program includes direct labor costs: salaries of the
providers, benefits cost, malpractice coverage, and billing costs. The volume of patient
visits, the payer mix, and the distribution of CPT codes reported determine the direct
patient care revenues of the practice. The medical director who typically has responsibility
for driving hospital outcomes determines any additional revenues. According to a survey
conducted by the Society of Hospital Medicine in 2014, 89.3% of hospitalist programs

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required a subsidy or fee to help with the payer mix of the unassigned patients, night call
coverage in-house, and for those organizations that focus on driving performance through
service offerings. The ranges of fees hospitals pay range from $0 per year to $250,000 per
physician annually. Fees are typically based on scope of work and payer mix.

SETTING THE COMPENSATION MODEL

In conjunction with determining the cost of the program, a compensation model must be
established. In the past decade, two significant challenges drove hospitalist
compensation: an imbalance of supply and demand, coupled with the rapid rise of
salaries that began escalating in 2001. This phenomenon has created a significant
compression in salaries. Often the least experienced physician’s compensation is closely
aligned with the most experienced physicians in the practice. This compensation
compression creates a dichotomy in the reward system on physician skill and experience
levels creating challenging team dynamics. There are two primary models: a productivity
model or a salary model. Many salary models also include a component of compensation
focused on productivity and quality metrics as well as outcomes.

Recruiting a team of physicians and hiring a leader is a critical core competency for
every hospitalist practice as discussed in Chapter 25. Acquiring effective recruiting
techniques is an area of investment that should not be minimized or overlooked in the
development of a strong hospitalist practice.

GROWING A HOSPITALIST PRACTICE
SETTING PRIORITIES FOR GROWTH

Once the practice launches, priorities must be established for the growth of the hospitalist
program. If the unassigned patients are already covered in the practice, the next step could
be a myriad of other opportunities, including contracting with PCP practices. It is essential
to understand the scope of growth and prepare in advance of the patients’ arrival. Many
practices have failed or imploded by taking on more growth than they could handle. If
there is a desire to handle 15 more patients per day with a 7 days on/7 days off model, it
might be as simple as figuring out the need to hire two more physicians. However, if the
program is already quite busy and adding three to four new admissions per day is in the
growth plan, adding an admitting shift may be called for as well.

PRACTICE POINT
Use these common areas of practice management and determine whether you are
prepared to grow.
Reflect about your hospitalist practice:

What are your priorities?
What are your goals and core values?
What effort can you invest to grow?

What are the expectations of external interests?

Performance measures.

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Satisfaction of outside primary care physician groups.
The Joint Commission requirements.
ACGME.
Public performance reporting, obtaining ≥ 90% core measure scores.

What is your work environment saying about the practice?

Patient safety, quality, satisfaction.
Efficiency of care.
Career satisfaction that integrates core values.
Service excellence and patient safety.
Continuous quality improvement and innovation.
Professional growth, leadership, and scholarship.

What are the expectations of hospital management?

Caring for unassigned/uncompensated patients.
Reducing ALOS for top 10 DRGs by hospitalist discharge volume.
24/7 service demands.
Reducing practice variation of hospitalists.
Hospitalist training on palliative care, end-of-life, and other medical specialties.
Development of a comanagement consulting service or a preoperative testing center.
Improvement of patient ED to floor times.
Care of admitted patients in the ED.
Managing the chest pain unit or rapid admission team.
Improvement of chart documentation for core measures (such as smoking cessation
counseling).
Improvement of billing for services provided.
Leadership of rapid response teams for ill inpatients.
Development of a transitional care program to address continuity of care in postacute
facilities or providing care in the patient’s home.

Does the practice have these evaluations and measurements in place?
Report card for hospitalists.
Primary care physician survey.
Multiyear strategic planning, quarterly reports.
Hospitalist career satisfaction survey.
Hospitalist annual retreat with management to establish goals.
Develop a 3-year plan for a hospitalist service that mirrors the hospital’s multiyear
plan.
Create a meaningful, motivating, and achievable blueprint for clinical enterprise.

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Proactively support mission of patient care, quality improvement, and patient-centered
care.

DEFINING KEY STAKEHOLDERS

The key stakeholders in the practice need to be clearly defined. Certainly, the doctors and
advanced practice team members in the practice are key stakeholders, but in many
practices the hospital administration is also a key stakeholder. Identifying priorities is
much like a game of chess. For example, if you choose to help solve another primary care
group’s needs before helping the orthopedic group with comanagement needs there may
be repercussions. You should expect that the hospital administrator want to weigh in on
how this decision impacts the hospital and its development plans.

INCORPORATING ADVANCED PRACTITIONER PROVIDERS

Another key decision for program growth is how to incorporate advanced practice
providers in the practice. While this topic is covered in the literature, there are plenty of
mixed opinions on the use of advanced practice providers in the inpatient setting. We have
found two main areas of optimal benefit in our practices.

The first benefit for incorporating nurse practitioners (NPs) and physician assistants
(PAs) is in very small programs of four full-time physicians with a daily census that can
have dramatic swings around the average. The cost of an NP or PA provider is about one-
half the labor cost of a physician, and this can be a cost-effective way to leverage the
existing physician coverage.

There is also a benefit from the use of advanced practice providers (APPs) in very large
programs, particularly in the management of surgical patients for their comorbid
conditions. Many practices have incorporated APPs due to the physician shortage and a
failure to recruit and retain high-quality physicians. One unique challenge is that many
APP’s value comes from their experience. An APP practicing in the acute care setting for
10 years is much more likely to be able to function as a hospitalist than a new graduate
APP. For hospitalist physicians, there is clearly value and competency in new a physician
starting to work directly upon completing their training. It is crucial to understand both the
state and hospital-specific by-laws associated with the use of NPs and PAs. Without such
understanding, the proposed program plan could be rejected by the hospital. For example,
if the rules state that the NPs’ work must be signed off and reviewed by a hospitalist it
does not create the same workforce multiplier as a site where on the right patients, the NP
can operate relatively independently.

TYPES OF PHYSICIANS IN THE PRACTICE

Another area of importance in growing a hospitalist practice involves the types of
physicians utilized. It is becoming more common to have family medicine-trained
hospitalists practicing alongside internal medicine hospitalists in the same practice. Much
has been debated on this topic and today nearly 10% of hospitalists nationwide are family
medicine trained. Factors that go into the determination to hire them include their comfort
level with ICU patients and their experience managing the higher-level acuity patients.
Another challenge is their ability to navigate the local politics associated with an internal
medicine outpatient practice referring its inpatient practice to a family medicine physician.

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We have found that the experience of the provider trumps all board certification. There are
plenty of internal medicine physicians unqualified to practice as hospitalists as well.

THE PROS AND CONS OF CAPS ON SERVICES

During the hospitalist practice growth phase, the group must be able to handle all of the
new patients it agreed to accept or have a Plan B. Plan B might include a floodgate that
closes in the form of a cap. This has been achieved at some hospitals to maintain safe
and effective volumes. Two types of caps exist including those requiring a backup
system. The backup system can be the existing hospitalists at a very high labor cost to a
hospital or the new group of primary care physicians who have asked for coverage; this
group may need to agree to provide occasional coverage at the hospital. The latter group
of physicians tends to be a short-term patch; they can quickly lose their skills and
credentialing in the inpatient setting. Ideally, if the hospitalist group has agreed to accept a
new group of patients, they need to have the capacity 24 hours per day, 7 days per week. A
“sick call” rotation to cover anticipated maternity and paternity leaves as well as
unexpected absences may have the benefit of allowing hospitalists to focus on career
development, especially quality improvement initiatives when they are not seeing patients,
and not overwhelming them with service obligations.

MANAGING THE HOSPITALIST PRACTICE
SELECTING THE RIGHT LEADERSHIP AND STRUCTURE

There is a shortage of high-quality physician leaders in the United States. To properly
manage the practice, it is critical to appoint the most capable physician leader and
establish an effective practice structure. The hospitalist leaders’ roles are complex; they
not only serve the hospitalists’ team but also play significant roles within the hospital. In
these roles, hospitalist directors are the most connected to how things work on a daily
basis. Strong hospitalist physician leaders must lead by example. They must have
effective organizational skills, be great communicators, and seek win-win situations for
the hospitalist team, medical staff, and hospital. Hospitalist leaders also need to be aware
of the professional goals of their members and delegate some responsibilities so that
each member can also flourish and find a professional niche within the organization.
Hospitalist directors may become isolated in their role, so it is important to ensure that
they have advocates or mentors who can promote their agendas as well as provide
counseling related to hospital politics. See Chapter 6: Leadership.

Many hospitalist programs include a version of shift work. This type of schedule
combined with the Generation Y culture in medical school today, centered on work hours
and patient volume restrictions, have led to a unique challenge in hospital medicine. Many
physicians seek direct employment models. They place a very high level of value for time
off. This can make it challenging to engage them in what matters to make a practice
successful. Ensuring the right fit begins with the initial interview when performance
expectations are clearly articulated.

CREATING AN OWNERSHIP MENTALITY

Like any small business, an ownership mentality is essential to the success of the
hospitalist practice. It is ideal to introduce the importance of the ownership mentality
expected during the hiring process. Those applicants who give solid examples of times in

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their career where they got involved, highlight scenarios when they did things because they
thought no one else could do it better, and are passionate about those experiences is
telling of their potential. These are typically indicators that the physician is the type of
hospitalist who can make the practice excel. Defining the behaviors that support the
values of the practice and then evaluating and rewarding those behaviors goes a long way
to reinforcing what is important. For example, if participating in hospitalist committees is
important and it can be rewarded as part of how the productivity dollars are allotted.
Leading a hospital committee or playing a leadership role within the medical staff could
be rewarded to an even greater extent.

SETTING UP THE RIGHT PROCESSES

Part of managing the practice is ensuring that the right processes are in place. Processes
should be established for physician scheduling and daily case management meetings.
Hospitalist processes should be highly sophisticated to drive improvements in utilization,
documentation, discharge planning, and prospective quality metric monitoring. All of these
processes require a tremendous amount of time, energy, and in many cases, technology
and infrastructure to drive clinical and financial performance for the hospital and
hospitalist practice.

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CHAPTER 26
Negotiation and Conflict Resolution

Leslie A. Flores, MHA

INTRODUCTION
Hospitalists face the potential for conflict every day. They work in highly complex
organizations and in order to be successful they must interact effectively with a wide
variety of individuals in what is often a challenging, emotionally charged environment.
Hospitalists must learn to navigate not only the formal organizational bureaucracy of
rules, systems, and processes, but also the informal political hierarchy that influences
power and decision making. Often, they must do so with little or no formal training in
conflict management at an early stage in their medical careers. In addition, they may
encounter conflicts between what others would like them to accomplish and their own
workload demands and professional expectations.

Hospital Medicine is also a young, evolving specialty that has enjoyed unprecedented
growth by serving the needs of multiple competing stakeholders. Although the specialty is
maturing, it is still populated by a high proportion of recent residency graduates and early-
career clinicians who may not have a complete understanding of the specialty or even
have career advancement on their radar screen. The potential exists for the service
obligations—both clinical and in the area of institutional performance improvement—of
hospitalists to overwhelm opportunities for professional development, and this may
promote career dissatisfaction, turnover, and symptoms of burnout. Leaders of hospitalist
services may find themselves isolated as they advocate for the professional development
and job satisfaction of group members while meeting the service expectations of their
employers or supervisors. The professional medical society for hospitalists, the Society of

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Hospital Medicine, is rapidly developing flexible support resources for hospitalists relating
to business and clinical practice, engagement and career satisfaction, core competencies,
and role expectations. Until these standards become widely disseminated and health care
services become better designed and hence less prone to error, hospitalists will continue to
work in a hospital environment where they will increasingly be expected to perform as
change agents at a time when change may not be welcomed by their hospitalist
colleagues or others at their institutions.

For the purposes of this chapter, it will be important to distinguish between
disagreements and conflicts. Disagreements happen regularly in human interactions, and
occur whenever two or more individuals have differing opinions about something. A
disagreement need not devolve into a conflict, and many do not. Conflicts arise when a
party perceives that another party has negatively affected or will negatively affect
agendas that the first party cares about. Conflicts are defined as processes that occur
when tensions develop, that is, the emotions associated with a disagreement become so
elevated that they impede the ability of the parties to interact with each other effectively.

Almost all conflict is a result of unmet expectations. For hospitalists, this commonly
arises when there is a lack of understanding or a difference in expectations about their
role. Hospitalists may assume that primary care physicians have explained to patients
that someone else will be seeing them in the hospital. Patients and families, however, may
not understand why their primary care physician is not present in the hospital and
directing their care. Emergency Medicine physicians may expect the hospitalist to respond
promptly to take a complicated social admission off their hands whereas hospitalists may
feel that it is the role of the emergency room physicians to discharge patients who do not
require admission. Emergency Medicine physicians and staff may expect for patients be
triaged to hospital floors (to reduce emergency department length of stay) before critical
information is available, or may expect hospitalists to care for patients in the emergency
department when no beds are available. Meanwhile, floor nurses may expect hospitalists
to be immediately available to address nonurgent requests. There may be differences of
opinion among specialists and generalists regarding diagnosis, workup, and treatment or
the role of the hospitalists in comanagement of specialty patients. All physicians expect to
be treated professionally, to have some autonomy over clinical decision making, and to
have a reasonable work-life balance. Hospital administrators and employers, however,
may demand that hospitalists to perform nonphysician tasks or solve problems for other
physician groups without taking into account the perspectives of the hospitalists or
staffing needs for time-consuming tasks. When such expectations go unmet, people get
frustrated or angry. They often respond in ways that then heighten frustration or anger on
the part of others. Emotions on both sides become elevated, and the stage is set for a
conflict.

PRACTICE POINT

Almost all conflict is a result of unmet expectations. For hospitalists this commonly
arises when there is a lack of understanding or a difference in expectations about their
role.

The most common reasons that expectations go unmet include:

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Lack of Clarity About What is Expected, or About How the Expectation Will Be Met.
It is easy to assume that because one’s expectations are clearly understood by
oneself, they are clear to others as well. Hospitalists may assume a patient
understands the proposed treatment plan, but the patient or family member may fail
to understand the implications for likely discharge plans. Even when expectations
are carefully explained, the other party may hear or interpret them differently than the
speaker intends. The other party may also react more to the emotional aspect of the
discussion or who is doing the talking rather than to the content.
Lack of Agreement About What is Expected Or How to Achieve It. The high degree
of complexity in error prone health care systems, stress and pressure, and the need
for rapid change are important sources of potential conflict. Sometimes each party’s
expectations are clearly understood by the other party, but they simply disagree with
each other about the desired outcome, the method of achieving it, or both. This can
occur if the parties have competing needs or interests. For example, although
resident work hour restrictions are clearly delineated in the academic setting, stress
and pressure develop for hospitalists when the increased service obligations
resulting from such restrictions conflict with their expectation for professional
advancement. All parties may agree on the importance of improving patient flow
from the Emergency Department to the inpatient floor, but may disagree about the
specific methods to be employed by Emergency Medicine physicians, hospitalists,
and others to achieve this goal. Changing hospital processes to promote improved
quality or greater efficiency often demand changes to hospitalist work flow that are
stressful for the hospitalists.

In addition, age, gender, and cultural differences may play a role in the development
and management of conflict. A generational gap may result in differences in work
expectations, a paternalistic view of who is actually in charge, or resistance to changing to
new work requirements. Men and women may have different expectations of their work,
and often have different ways of responding to stress, emotion, and conflict. In the United
States, men often tend to use a competing or forcing style when faced with conflict,
whereas women often tend to use compromising, accommodating, and avoiding.

A key aspect of cultural differences is the degree to which a person tends to identify
most strongly with the group of which he or she is a part (a “collectivist culture”) as
opposed to identifying with the self (an “individualistic culture”). Individualistic cultures,
which are the dominant cultures found in North America and Western Europe, value
autonomy, creativity, and personal initiative. Much of the rest of the world is composed of
collectivist cultures, which instead value conformity and harmony. A meta-analysis of
studies on culture and conflict resolution styles found that people in individualistic
cultures tend to choose forcing as a conflict style more often and people who come from
collectivistic cultures tend to choose withdrawing, compromising, or problem-solving
styles instead.

THE POTENTIAL BENEFITS OF CONFLICT
Conflicts are inevitable in human interactions. The increasingly complex and collaborative
nature of the work that hospitalists do as team-based care models have emerged
increases the risk that interpersonal conflicts may arise. The increasing cost pressures and
competition for scarce resources that exist in an era of national health care reform have

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increased stress and opportunities for conflict for all health care professionals. These
conflicts can be destructive if not effectively managed. But a healthy approach to conflict
management acknowledges that not all conflict is entirely negative. There are potential
benefits that may be derived from conflicts under certain circumstances. DeChurch and
Marks (2001) reported that the ways in which groups handle conflict help to determine
whether or not benefits were realized, noting that “the relationship between task conflict
and group performance was positive when conflict was actively managed and negative
when it was passively managed.” This suggests that Hospital Medicine physicians will be
well served to develop effective conflict management skills that can help them increase
the likelihood that the conflicts they will inevitably face may yield positive results. In order
to do so, it will be important for hospitalists to think strategically about how one may
extract the maximum benefit from conflicts that do occur. Some of the potential benefits
of appropriately managed conflict include:

Catalyst for Change. Conflicts can force needed change by surfacing problems that
otherwise might not be recognized, and by elevating latent issues to a level that
demands attention. This can be especially valuable in tradition-bound, change-
resistant organizations.
Improved Outcomes. Similarly, conflicts can ultimately yield improved outcomes
when they facilitate learning in the search for better solutions and bring to the
forefront useful information and emotions that lie below the surface.
Balance. Healthy conflict helps to ensure that balance is maintained among
competing needs and perspectives.
Increased Accountability. Because conflicts involve strong emotions, healthy
conflict resolution usually involves careful articulation of what the parties have
agreed to do to resolve it, and a significant degree of accountability to ensure that
the agreements are followed through.
Improved Relationships. When people skillfully manage a conflict in healthy,
respectful ways, it can actually serve to strengthen their relationship going forward.
They end up understanding each other better, and building greater trust because they
have demonstrated that they can overcome differences.

KEY PRINCIPLES IN CONFLICT MANAGEMENT

This chapter offers five key principles that represent a good start for those who wish to
build better conflict management skills (Table 26-1). However, more detailed treatments of
all of these principles and others are contained in the references at the end of this chapter.

TABLE 26-1 Five Key Principles of Effective Conflict Management

1. Commit to confronting
2. Attend to the conditions
3. Identify one’s personal contribution
4. Consider what is underlying others’ behavior
5. Clarify

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1. Commit to Confronting. Most people tend to shy away from conflict. It is tempting
to believe that the problem will go away by itself if left alone; that others will soften
their positions, forget about the issue, or change their minds, if given enough time.
But when pressed, most people will acknowledge this is simply a convenient excuse
for avoiding a confrontation that they fear could become uncomfortable or out-and-
out unpleasant. Another important reason that people avoid conflict is their fear that
openly confronting the situation will make things worse, rather than better. They
may worry about handling the confrontation badly and unintentionally causing the
situation to deteriorate, or they may fear that the conflict is intractable and that no
matter how carefully and skillfully the situation is handled, the outcome will be
negative.

In fact, conflicts cannot be resolved if they are not confronted. They may be glossed
over or pushed into the background, but not truly resolved. And such conflicts are likely to
surface again, often in unanticipated and damaging ways. Thus, a willingness to
acknowledge the existence of a conflict and to step up and confront it is a precondition to
effectively managing the conflict.

PRACTICE POINT

A willingness to acknowledge the existence of a conflict and to step up and confront it
is a precondition to effectively managing the conflict. This requires an open and
honest discussion of the issue, usually face to face, with the goal of understanding the
root causes (the unmet expectations) that led to the conflict and addressing them.

In this context, the term “confrontation” is not intended to mean an angry, emotional
exchange of verbal attacks. Instead, “confrontation” refers here to an open and honest
discussion of the issue, usually face to face, with the goal of understanding the root
causes (the unmet expectations) that led to the conflict and addressing them. The
remaining principles in this secion are intended to assist the confronter, once the decision
to confront has been made, to carefully plan the confrontation (when time permits), and to
handle it successfully.

2. Attend to the Conditions. Patterson et al (2002) note that there are two components
to every successful crucial conversation: the actual content of the conversation, and
the conditions under which the conversation occurs. Most people, when planning to
confront or actually engage in a confrontation (a “crucial conversation”), think
primarily about the content of the conversation: “What is this conflict about? What
steps will resolve it? What points do I need to be sure to make? What will I say to get
my points across? What will the other person say?”

People skilled in conflict management realize that the conditions matter just as much
as—in fact, maybe more than—the content does. What types of conditions matter? The
physical conditions matter a great deal. Is the conversation taking place in a private place
instead of in public? Are the people involved in the conversation sitting or standing so they
can engage each other at eye level, or is one person sitting with the other standing over

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him? Is there a desk or other impediment between the participants? Is the room too large
or too small, too hot or too cold to be comfortable?

Psychological conditions matter even more. The hospitalist who wishes to be skilled at
conflict management must learn to pay attention to what the other person or people
involved in the conflict are experiencing emotionally. Are they feeling attacked or are they
feeling safe? Do they feel that the hospitalist respects them and has their best interests at
heart, or do they feel that their interests will be ignored or belittled? Do they sense that the
hospitalist is going to push her agenda or opinion and ignore theirs, or do they believe the
hospitalist is willing to listen and take their point of view into consideration? Do they feel
that the hospitalist’s opinion matters, or that dialogue should occur at a “higher level” with
senior physician leaders to the exclusion of hospitalists?

Before the actual content—what the conflict is about and how it should be resolved—
can be effectively addressed, the skilled conflict manager must take steps to set up
conditions that allow all parties to feel comfortable, safe, and heard. The necessary steps
to creating these positive conditions involve ensuring mutual respect among the parties,
and identifying or creating a mutual purpose. In other words, do others believe the
hospitalist sees them as individuals worthy of the respect and consideration due to every
human being, and do they believe that the hospitalist is mindful of their interests as well
as his own in seeking an acceptable resolution?

PRACTICE POINT

Before the actual content—what the conflict is about and how it should be resolved—
can be effectively addressed, the skilled conflict manager must take steps to set up
conditions that allow all parties to feel comfortable, safe, and heard. The necessary
steps to creating these positive conditions involve ensuring mutual respect among the
parties and identifying or creating a mutual purpose.

3. Identify One’s Personal Contribution. Conflicts occur when emotions get in the way
of resolving disagreements. This is true not only of others with whom a hospitalist
may come in conflict, but of the hospitalist himself. Another important competency
for skilled conflict managers is the ability to step back from their own emotions and
assess their personal contribution to the situation; in other words, what impact are
their own biases, assumptions, emotions, and actions having on the conflict itself,
and on their approach to managing it? Do they truly intend to seek mutually
acceptable solutions or do they just want to win?

For example, the person seeking to manage a conflict must pay attention not only to
what others are experiencing emotionally but also to what he is experiencing emotionally
himself. He needs to ask, “Am I feeling safe or am I under attack? Do I believe the others
involved in this conflict will listen to me and take my interests into consideration, or not?”
However, simply identifying one’s own emotional state is not adequate. Effective conflict
managers should also have the self-awareness to understand how their emotions will tend
to influence their behavior in the confrontation. These tendencies are described as a
person’s “style under stress.”

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The Style Under Stress Inventory3 in Table 26-2 is based on the concept of
conversational safety, and will assist individuals in assessing their own personal style
under stress. In completing the questions, one should answer “T” for true or “F” for false,
based on one’s most common tendencies when in conflict situations in the work setting.
People feel safe in a crucial conversation if they believe that they will be listened to
respectfully and if they do not feel attacked or ignored. They feel that the other parties
have their interests at heart, or at least that others’ interests and their own are not
diametrically opposed without room for finding common ground. The inventory is
designed to help people understand how they tend to behave when they do not feel safe in
a crucial conversation.

TABLE 26-2 Style Under Stress Test

1. Rather than tell people exactly what I think, sometimes I rely on
jokes, sarcasm, or snide remarks to let them know I’m frustrated.

T F

2. When I have got something tough to bring up, sometimes I offer
weak or insincere compliments to soften the blow.

T F

3. Sometimes when people bring up a touchy or awkward issue I try to
change the subject.

T F

4. When it comes to dealing with awkward or stressful subjects,
sometimes I hold back rather than give my full and candid opinion.

T F

5. At times I avoid situations that might bring me into contact with
people I’m having problems with.

T F

6. I have put off returning phone calls or e-mails because I simply did
not want to deal with the person who sent them.

T F

7. In order to get my point across, I sometimes exaggerate my side of
the argument.

T F

8. If I seem to be losing control of a conversation, I might cut people
off or change the subject in order to bring it back to where I think it
should be.

T F

9. When others make points that seem stupid to me, I sometimes let
them know it without holding back at all.

T F

10. When I’m stunned by a comment, sometimes I say things that
others might take as forceful or attacking, comments such as “give
me a break!” or “that’s ridiculous!”

T F

11. Sometimes when things get heated I move from arguing against
others’ points to saying things that might hurt them personally.

T F

12. If I get into a heated discussion, I’ve been known to be tough on the
other person. In fact, they might feel a bit insulted or hurt.

T F

Excerpted with permission from Patterson K, Grenny J, McMillan R, et al. Crucial Conversations: Tools
for Talking When Stakes are High. New York, NY: McGraw-Hill; 2002.

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Individuals responding “true” for several of the first six questions are said to be going
to silence when under the stress of a challenging conflict situation. This means they will
tend to try to downplay or sugarcoat an issue, or even avoid it outright by changing the
subject or disengaging when they do not feel safe. In such cases, they may believe that
they have raised an issue and articulated their concerns, but others may be left confused
or unaware of how strongly the person feels about the issue because of his silence
tendencies. On the other hand, answering “true” to some or all of questions 7 through 12
means the person tends to go to violence when feeling unsafe in a conversation. These
people will often try to force their opinion on others by controlling the conversation and
either prevent others from speaking or belittle their contributions when they do.

Both silence and violence can be extremely damaging, when the goal of the
conversation is to confront disagreements and work toward mutually acceptable
solutions. When people understand their own silence or violence tendencies, they can
begin to pay attention to how they are responding during conflict situations. They can look
for evidence that they are not feeling safe and then step back to assess the impact their
silence or violence is having on the conversation and adjust their interactions accordingly.
As awareness of these tendencies grows over time, people can begin to anticipate
situations in which safety may be at risk and to proactively develop plans to manage their
own tendencies to go to silence or violence.

When thinking about one’s personal contribution to a conflict situation, one should also
be cognizant of individual assumptions and biases about others involved in the conflict,
and especially one’s beliefs about others’ intentions. For example, it is usually helpful to
consider the problem of intent versus impact. When analyzing a conflict, one should
consider asking, “Is it the impact (ie, the outcome) of the other person’s behavior that is
bothering me so much, or is it what I believe about the person’s intentions?”

This distinction is important because humans tend to overemphasize dispositional
factors such as personality type or motives, and to discount situational factors such as
external stressors, when interpreting the behavior of others; this phenomenon is known by
psychologists as the fundamental attribution error or correspondence bias. Because of
this bias, the emotions a person experiences about a disagreement, and thus the level of
conflict that ensues, may be heightened as a result of presumed negative intentions on the
part of others (“that surgeon is just lazy”) and discounting the circumstantial factors that
may be influencing others’ behavior (“that surgeon is under real pressure to produce good
outcomes, and does not have the training or experience to manage these complex
medication regimens”).

The fundamental attribution error may be exacerbated by a related tendency known as
the actor-observer bias in which one tends to attribute others’ behavior to their dispositions
but to attribute one’s own behavior to the circumstances (“that family member lost her
temper because she’s a demanding jerk, but I only lost my temper because she pushed me
over the edge”). Self-awareness is critical for effective conflict management, especially
awareness of one’s own assumptions and biases.

PRACTICE POINT

Self-awareness is critical for effective conflict management, especially awareness of
one’s own assumptions and biases.

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4. Consider What is Underlying Others’ Behavior. One of the keys to effective conflict
management is the ability to analyze why others respond the way they do in conflict
situations (taking into account both dispositional factors and situational factors),
and to modify one’s interactions accordingly. The concept of conversational safety
applies to the other parties involved in a conflict situation, as well as to oneself.
Skilled conflict managers become adept at not only reading and adjusting their own
behaviors, but also at looking for signs that others are not feeling safe. Hospitalists
may become more accepting of the anger expressed by patients’ families, the
critical comments from other medical staff members, or the sugar-coated change of
subject by the hospital executive when they realize that these behaviors often result
from others’ fear(s) that they will be treated with disrespect, attacked, or ignored. If
they can then work to address those underlying fears (part of paying attention to
conditions) before launching into the content of the conversation, they will be more
successful.

PRACTICE POINT

One of the keys to effective conflict management is the ability to analyze why others
respond the way they do in conflict situations (taking into account both dispositional
factors and situational factors), and to modify interactions accordingly. When
someone acts in ways that contribute to a heightened level of conflict, it is worth
considering whether that person has underlying human needs that are going unmet
and that are contributing to his or her challenging behavior.

Another way of thinking about this issue is to anticipate that the more significant the
conflict, the greater the chance that people will respond to it emotionally rather than
logically. While it is not a clinically accurate model, it may be useful to think of peoples’
brains as having a logical core, surrounded by a layer of emotion (Figure 26-1). Every
interaction a person has, no matter how logical it is, passes through this emotional filter
on its way in or out.

Figure 26-1 Logic and emotion diagram.

For most people and under normal circumstances, the layer of emotion surrounding
the logical core is relatively thin and the information from the interaction passes through it

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in both directions, informed by the emotion but not substantially altered by it. In a conflict
situation, however, the emotional layer surrounding the logical core inflates like a balloon.
In this situation, the expanded emotional layer takes over and prevents logical
conversation and data from passing through. The person is responding from her or his
emotion, rather than from logic. A hospitalist may be attempting to have a very logical
conversation with a family member, assuming that she is addressing the family member’s
logical core. But the hospitalist’s logical words cannot get through the family member’s
inflated emotional layer. The hospitalist is talking logic, and the family members are
responding from emotion; so no wonder they are unable to relate to each other. In such
situations, it is necessary to let some air out of the balloon—to give the emotional layer a
chance to deflate—before it will be possible to re-engage the logical core in problem
solving or conflict resolution. Sometimes this requires stepping away from the
conversation for a while and coming back to it later.

In addition to the overwhelming influence of emotion on how others respond to conflict
situations, Heifetz and Linsky (2002) have argued that there are powerful and universal
human needs that influence behavior, sometimes in dysfunctional or disruptive ways:

Every human being needs some degree of power and control, affirmation and
importance, as well as intimacy and delight…. We all have hungers, which are
expressions of our normal human needs. But sometimes those hungers disrupt
our capacity to act wisely or purposefully. Perhaps one of our needs is too
great and renders us vulnerable. Perhaps the setting in which we operate
exaggerates our normal level of need, amplifying our desires and
overwhelming our usual self-controls. Or, our hungers might be unchecked
simply because our human needs are not being met in our personal lives.

When someone acts in ways that contribute to a heightened level of conflict, it is worth
considering whether that person has underlying human needs that are going unmet, and
that are contributing to his or her challenging behavior.

5. Clarify. When confronting another person about a conflict situation, effective
communication skills are essential. It is important to clarify what one is attempting
to convey; it is also important to clarify the other person’s point of view. Important
communication skills include

Setting the stage. Keeping in mind the principles of mutual respect and mutual
purpose, it may be valuable to start out by communicating one’s own positive
intentions to the other person(s) in a way that builds toward these goals.
Managing expectations. Hospitalists should clearly communicate what their own
expectations were in the situation that gave rise to the conflict, and seek to
understand what the other person’s expectations were. This will create a
foundation for further dialogue about the differences between what each party
expected and what actually occurred.
Active listening. Active listening skills involve not just hearing what the other
person says, but also

actively engaging the other person with eye contact and body language;

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working to enable the other person to feel comfortable sharing potentially
difficult information;
listening “between the lines” for what is not being said, as well as what is being
said;
acknowledging the reality and legitimacy of the other person’s emotions;
paraphrasing and reframing to ensure understanding of the other person’s
perspective;
asking questions and probing to understand root causes;
staying focused on the other person, rather than one’s own planned response.

Joint problem solving. Engaging all parties to the conflict in joint problem solving
will help to clarify what needs to happen to resolve the conflict, and what the
alternatives are for moving forward out of conflict. It will also help build mutual
support of and commitment to the agreed-upon approach.
Articulating next steps. Establishing a clear path of next steps and assigning
responsibilities are vital components of a clear and effective communication
process. It is worth talking both about the expected outcome, and about the
method or process by which the outcome will be achieved: it is not uncommon for
new conflicts to arise inadvertently when two parties believe they understand
what will happen, only to clash over how it will be accomplished.

PRACTICE POINT

When confronting another person in a conflict situation, effective communication
skills are essential. It is important to focus on ensuring clarity, both in what one is
attempting to convey, and in understanding the other person’s point of view. Important
communication skills include setting the stage, managing expectations, active
listening, joint problem solving, and articulating next steps.

STRATEGIES FOR EFFECTIVE CONFLICT MANAGEMENT: CONFLICT
RESOLUTION AND NEGOTIATION

1. The Talking Stick. Stephen Covey (1989) highlighted the importance of empathetic
communication in describing the principle, “Seek first to understand, then to be
understood.” Covey (2004) further described the use among Native American
cultures of the Talking Stick as a tool to help people resolve differences by creating
greater mutual understanding and respect.5 The Talking Stick is passed from one
person to another, and only the person who is holding the Talking Stick is allowed to
present her or his perspective. This ensures that only one person talks at a time, and
increases the ability of others to listen because they are not permitted to argue or
make their own points until the person holding the Talking Stick has finished.

The most powerful aspect of the Talking Stick, however, is that the person holding it
does not relinquish it until she is satisfied that she has been fully understood by the
others. It is the responsibility of the listeners to listen carefully and with empathy, and to

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ensure that the speaker feels understood—not necessarily agreed with—just understood.
Once the speaker is satisfied that others understand him, she passes the Talking Stick on
and assumes the responsibility to listen and make the next speaker feel understood.
Covey describes the value of the Talking Stick as follows:

This way, all of the parties involved take responsibility for one hundred percent
of the communication, both speaking and listening. Once each of the parties
feels understood, an amazing thing usually happens. Negative energy
dissipates, contention evaporates, mutual respect grows, and people become
creative. New ideas emerge. Third alternatives appear.

One does not need to use a physical Talking Stick to gain these benefits. It is possible
to establish a framework for interacting in which the parties agree that they will alternate
the responsibilities of talking and listening until both feel fully understood. This process
can be very effective in facilitating the resolution of conflicts between hospitalists and
other specialists regarding scope and service issues. Some parties may be able to do this
independently, while others may benefit from facilitation by a third party mediator.

2. Unhappy Patients and Families: Take the HEAT. Some of the most challenging
conflicts that hospitalists must manage are those that involve the unmet
expectations of patients and families. Keeping in mind the role of emotion in
conflict, Byham (1993) recommends the following approach for those who are
responsible for addressing the needs of unhappy patients and families, as
summarized by the acronym “Take the HEAT”:

Hear them out. Active listening without interrupting, disagreeing, or defending is
the crucial first step. Angry patients and family members need to be able to
express their emotions in order to let some of the air out of the emotional balloon.
Empathize. As with Covey’s Talking Stick example, patients and families need to
feel understood. It is not necessary to agree with them, but it is important to
acknowledge their feelings and to attempt to understand the issue from their
perspective.
Apologize. Byham points out that even if one does not wish to admit fault, it is
important to apologize for the situation, and for the fact that the patient’s
expectations were not met.
Take responsibility for action. Once the emotional balloon has been deflated, it is
often possible to re-engage the patient or family member on a logical basis. A
good way to make this transition is to take some concrete action, either to resolve
the problem on the spot or to demonstrate a desire to improve the situation.

3. Principles of Effective Negotiation. Hospitalists frequently find themselves in
potential conflict situations in which negotiation is an effective strategy for
addressing the issue. These may include formal negotiations such as the
development of professional service agreements, employment contracts, or
incentive compensation metrics, or they may be less formal interactions such as
working with specialists to define admitting responsibilities or co-management
services. Strong negotiation skills are also valuable for hospitalists working on

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medical staff committees or quality improvement projects when the diverse
interests of many parties must be reconciled.

In traditional negotiations, each party stakes out a formal position and then proceeds
to bargain from that position, using various tactics to “win” points that bring the final
compromise outcome closer to this position. By contrast, the Principled Negotiation model
developed by Fisher and Ury (1981) focuses on understanding all the parties’ underlying
interests and on identifying objective, fair options that can satisfy everyone. The four
tenets of Principled Negotiation are as follows:

Separate the people from the problem. This principle addresses the role of
emotions and relationships in influencing one’s perceptions about the negotiation.
The authors suggest that negotiators seek to identify when relationships (either
as friends or adversaries) may be getting in the way of seeking the best outcome,
and that negotiators address these emotional aspects directly and openly with the
goal of moving beyond them into objective and collaborative problem solving.
Focus on interests, not positions. It is crucial to look beyond the formal stance a
person has taken and attempt to understand his underlying interests, the “root
causes” of his position. By understanding all parties’ basic interests (both one’s
own and the other person’s), one increases the chances of identifying new
perspectives or solutions that will meet both parties’ interests.
Invent options for mutual gain. The authors argue that once emotional and
relationship issues have been separated from the substantive problem, and all
parties’ underlying interests are understood, the role of the parties is to invent
better options. The steps in this process are: separating the identification of
options from the act of judging them, looking for many options rather than a
single answer, focusing on options that result in mutual gains, and then coming
up with ways to make the decisions easy.
Insist on using objective criteria. Finally, Fisher and Ury acknowledge that despite
one’s best efforts, negotiators will sometimes face situations in which interests
are truly in intractable conflict and mutually acceptable options may not be
available. In these cases, effective negotiators will insist that decisions be made
using objective, usually externally validated, criteria.

In addition to the tenets of Principled Negotiation outlined above, it is important to
recognize that when the issues are complex, even the best and most carefully documented
negotiation will probably fail to anticipate every nuance that may arise going forward. For
example, when hospitalists negotiate and memorialize a “service agreement” with a group
of specialists to define who will admit which types of patients, invariably a patient will
present who does not fit neatly into any of the categories specified in the service
agreement. If the potential for this to occur is not acknowledged and planned for up front,
additional conflicts may arise despite the parties’ careful efforts. The most valuable asset
in such situations is a strong underlying relationship of mutual trust and respect that will
enable the parties to resolve these issues on a case-by-case basis. The bottom line is that
even the best negotiation skills and most clearly drafted documents cannot substitute for
strong relationships.

CONCLUSION

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Conflict is inevitable in human interactions, and the potential for serious conflict will grow
as the complexity of interactions increases. The extremely challenging milieus in which
hospitalists practice are rife with misunderstandings, disagreements, and unmet
expectations, placing hospitalists at risk for conflict on a daily basis. Therefore, the ability
to understand and effectively manage conflict should be a core competency for all
hospitalists. The first step in building effective conflict management skills is to
understand the causes and potential benefits of conflict. Next, hospitalists should learn
and apply key principles of conflict management; and finally, hospitalists need to develop
competence and confidence in implementing useful strategies for managing different
types of conflict.

SUGGESTED READINGS
Covey SR. The 7 Habits of Highly Effective People. New York, NY: Simon and Schuster;

1989:235-260.
DeChurch LA, Marks MA. Maximizing the benefits of task conflict: the role of conflict

management. Int J Conflict Manag. 2001;12:4-22.
Gilbert DT, Malone PS. The correspondence bias. Psychol Bull. 1995;117:21-38.
Holt JL, DeVore CJ. Culture, gender, organizational role, and styles of conflict resolution: a

meta-analysis. Int J Intercult Relat. 2005;29:165-196.
Jones EE, Nisbett RE. The Actor and the Observer: Divergent Perceptions of the Causes of

Behavior. New York, NY: General Learning Press; 1971.
Patterson K, Grenny J, McMillan R, et al. Crucial Conversations: Tools for Talking when

Stakes are High. New York, NY: McGraw Hill; 2002.
Ross L. The intuitive psychologist and his shortcomings: distortions in the attribution

process. In: Berkowitz L, ed. Advances in Experimental Social Psychology. vol. 10.
Orlando, FL: Academic Press; 1977:173-240.

Thomas KW, Thomas GF, Shaubhut N. Conflict styles of men and women at six
organization levels. Int J Conflict Manage. 2008;19:148-166.

Triandis HC. Individualism and Collectivism. Boulder, CO: Westview Press; 1995.

REFERENCES
1. Patterson K, G