(856-L04) Conversations That Count: Achieving ...

Conversations That Count: Achieving Organizational Success Through Crucial Conversations and Crucial Confrontations

Stephen J. Davis, PharmD, MS, CPPSProgram Director, Health System Pharmacy Administration Residency

Texas Children’s HospitalHouston, TX

Disclosure

In accordance with the ACPE’s and ACCME’s Standards for Commercial Support, anyone in a position to control the content of an educational activity is required to disclose their relevant financial relationships. In accordance with these Standards, ASHP is required to resolve potential conflicts of interest and disclose relevant financial relationships of presenters.

• In this session:

All planners, presenters, reviewers, and ASHP staff report no financial relationships relevant to this activity.

Learning ObjectivesDefine the concept of crucial conversations and crucial

confrontations utilizing the framework from currentliteratureApply literature‐based and practical strategies for having

crucial conversations in experiential educationDevelop a plan to resolve issues and communicate

effectively during a crucial confrontationDistinguish opportunities for having crucial conversations

with students, residents, and preceptors

2018 National Pharmacy Preceptors ConferenceConversations That Count: Achieving Organizational Success Through Crucial Conversations and Crucial Confrontations

2018 National Pharmacy Preceptors Conference of 23

What’s a Crucial Conversation?

Crucial Conversations. https://vialogue.wordpress.com/2013/05/04/crucial‐conversations‐notes/. Accessed June 08, 2015.

What’s a Crucial Confrontation?

Missed commitments Bad behavior Violated expectations Broken promises

Patterson K, Grenny J, McMillian R, Switzler A. Crucial confrontations: Tools for resolving broken promises, violated expectations and bad behavior. New York: McGraw‐Hill; 2004.

Why Are These Concepts Important?Silence fails• Students, residents, preceptors

Silence killsPreceptors inadvertently use violent verbal

strategiesImpaired relationshipsDetriment to the profession

Patterson K, Grenny J, McMillian R, Switzler A. Crucial conversations: Tools for talking when the stakes are high. New York: McGraw‐Hill; 2002.

2018 National Pharmacy Preceptors Conference Conversations That Count: Achieving Organizational Success Through Crucial Conversations and Crucial Confrontations


Our lives begin to end the day we become silent about things that matter. – Martin Luther King Jr.

Preceptors Fear Crucial Conversations70% avoid difficult conversations with their boss, coworker,

or direct report38% say the most difficult topics to discuss are broken

promises, violated expectations, or competence concerns34% have put off holding a difficult conversation for at least

a month25% have put off holding a difficult conversation for more

than a year

VitalSmarts. http://cms.vitalsmarts.com/d/d/workspace/spacesstore/29512982‐0d6e‐4ccb‐9bb4‐2389f3bf358a/employees. Accessed June 09, 2015.

What Happened?

Emotions Under pressure Stumped Self‐defeating ways




Preceptors: Common Crucial Conversations and Confrontations

Giving a student/resident feedback about his/her behaviorGiving a preceptor feedback about his/her behaviorCritiquing a student’s/resident’s workDiscussing a student’s/resident’s knowledge deficitGiving an unfavorable summative evaluationTalking to a student/resident who isn’t keeping commitmentsSuspending a student/resident from a rotation or an institutionDismissing a student/resident from an institution

Speak when you are angry and you will make the best speech you will ever regret. – Ambrose Bierce

Importance of Dialogue

Must find a way to get all relevantinformation out into the open

Create a safe environment “Pool of Shared Meaning”




Start With Heart

Work on me firstFocus on what you really want• For myself, for the student, resident,

preceptor, and for the relationshipRefocus your brainFind your bearings


Learn to Spot Crucial Conversations

Physical signs• Eyes dry or water• Stomach gets tight• What are your cues?

Emotions• Scared, hurt, or angry

Behavioral• Raising/lowering your voice• Pointing your finger


YesNo

Question for the AudienceI have put off returning phone calls or e‐mails because I simply didn’t want todeal with the students, residents, or preceptors who sent them.



Withdrawing (Silence)

Pulling out of a conversation altogetherExit the conversation or exit the room


YesNo

Question for the AudienceI’ve been known to be tough if I get into aheated discussion with a student, resident, orpreceptor. In fact, they might even feel a bitinsulted or hurt.

Attacking (Violence)

Moving from winning the argument to makingthe person sufferBelittling and threatening




YesNo

Question for the AudienceWhen it comes to dealing with awkward or stressful subjects,sometimes I hold back rather than give my full and candid opinion.

Avoiding (Silence)

Steering completely away from sensitivesubjectsTalking without addressing the real issues


YesNo

Question for the AudienceIf I seem to be losing control of a conversation, I might cut people off orchange the subject in order to bring it back to where I think it should be.



Controlling (Violence)

Coercing others to your way of thinkingForcing your views on others or dominating

the conversationOverstating facts, speaking in absolutes,

changing subjects, or using directive questionsto control the conversation


YesNo

Question for the AudienceWhen I’m stunned by a comment from students, residents, or preceptors, sometimes I saythings that may offend them by using terms such as “You are a student!” or “When I was aresident” or “That preceptor is an idiot!”

Labeling (Violence)

Putting a label on people or ideas so we candismiss them under a general stereotype orcategory




YesNo

Question for the AudienceWhen I’ve got something tough to bring up, sometimes I offerweak or insincere compliments to soften the blow.

Masking (Silence)

Understating or selectively showing our trueopinionsSarcasm, sugarcoating, and couching


Learn to Look

Watch for conversation conditions• Signs of silence and violence • Signs that respect is violated• Learner does not feel safe




Break the Cycle

Do not get stuck in the content of the conversation

Do not give into the temptation Do not match their aggressive or

passive behavior• Remember this is a sign of their

violated safety

Step out of the conversation• Switch gears

Build safety• Focus on what you really want

Step back into the content


Make It Safe

Mutual Purpose – the entrancecondition• Perceive that you’re working

toward a common outcome• Perceive that you care about

their goals, interests, and values• Vice versa• CRIB


Mutual Respect – The Continuance Condition

Perceive that you respect themVice versaKeeps the conversation goingEstablishes dialogue towards the

mutual purpose




ApologizeApologize when appropriateSincerely express your sorrow for your role in

causing pain or difficulty• Give up saving face, being right, or winning• Sacrifice a bit of your ego by admitting your

error• 3 R’s = regret, responsibility, and remedy


What If…

Students, residents, or preceptors feel disrespected even though you haven’t done anything disrespectful?What if the insult is entirely unintended?

Contrast to Fix Misunderstanding

A don’t/do statement• Addresses others’ concerns that you don’t respect

them or that you have a malicious purpose (the don’tpart)

• Confirms your respect or clarifies your real purpose(the do part)

Provides context and proportionContrasting is not apologizingPatterson K, Grenny J, McMillian R, Switzler A. Crucial conversations: Tools for talking when the stakes are high. New York: McGraw‐Hill; 2002.



Interactive Scenario You’re about to talk to Suzie, a PGY1 resident, who defers blame,

makes excuses, and takes no accountability for her actions whenpreceptors try to give her feedback. Recently a preceptor attemptedto give her feedback on time management due to the fact that Suziehas shown a recent pattern of being tardy to patient careprogression rounds. Suzie informed the preceptor that traffic is bad,the elevators are always slow, and that her office is not near thenursing units. The preceptor has asked you to assist in offeringfeedback since you have also served as Suzie’s mentor.

Formulate An Up‐Front Contrasting Statement Hints

• Set the right tone• Lay out the context carefully• Learn to look

I don’t want________________________________________ I do want__________________________________________

Take a few minutes and try it!


What If…

There are different purposesThere is no misunderstandingContrasting is not working



Interactive Scenario Jim is a P4 student who is currently on an outpatient pharmacy

rotation at a hospital. He has informed you and the other P4students on your rotation that he has matched with a hospital tobegin a PGY1 residency. You have also overheard him mention to theother P4 students that he is not interested in outpatient and thatthis rotation is a “waste of time.” As a result, you notice that hedisplays a lack of interest for the outpatient pharmacy rotation anddoes not seem to be putting forth the effort that you expect from allstudents on your rotation. You decide to have a conversation withJim.

How would you begin the conversation with Jim?

Seek a Mutual Purpose

Hints• Perceive that you are working toward a

common outcome• Perceive that you care about their goals,

interests, and values• Perceive that you respect them• Vice versa• Learn to look• CRIB


What If…Jim: I didn’t want to do this outpatient pharmacy

rotation since it doesn’t align with my career interests.That is the reason I decided to do a residency. I feel as ifthe knowledge and experience from this outpatientrotation will not benefit me in my career. This rotationhas no value to me at all.You are overcome with strong emotions that are

keeping you stuck in silence or violence.



Master My Stories

Notice your behaviorGet in touch with your feelingsAnalyze your storiesGet back to the facts


STATE My Path

Share your facts (what)Tell your story (what)Ask for their facts, stories, and feelings (what)Talk tentatively (how)Encouraging testing (how)


Explore Others’ Paths

Four power listening tools (AMPP) AskMirror Paraphrase Prime




Let’s Apply What We Have Learned

Jim: I didn’t want to do thisoutpatient pharmacyrotation since it doesn’talign with my careerinterests. That is the reasonI decided to do a residency.I feel as if the knowledgeand experience from thisoutpatient rotation will notbenefit me in my career.This rotation has no valueto me at all.

Master my stories Seek a mutual purpose STATE my path Explore others’ paths

Take a few minutes and try it!

Interactive Scenario John is a PGY2 infectious disease resident. John has a reputation of

being smug and is associated amongst most of his peers as having a“know it all” attitude. During the first week of the rotation, youassign John a specific assignment to enhance his knowledge ofpharmacokinetics and pharmacodynamics of antimicrobial therapy.You assign the due date for the end of the week on a Friday at2:00pm. You also schedule a meeting during that time for John topresent his assignment to you. You notice John’s facial expressionshave changed and you hear him mutter something as he walks away,but you don’t think much of it.

Interactive Scenario It is now Friday at 2:00pm and John did not show up to

the scheduled meeting. You wait 30 minutes and thenpage John. John does not respond to the page. John hasanother meeting scheduled in the conference room onhis Outlook calendar from 3:30pm to 4:00pm in whichyou will be attending. John shows up to the 3:30pmmeeting and noticeably avoids making eye contact withyou. You decide to wait until this meeting is over beforeconfronting John.



Questions For YouHow do you feel?What would you do?• Would you immediately confront John or wait

until the meeting is over?How would you confront John?Would anyone choose not to confront John?• Maybe confront John after the weekend?

Interactive Scenario After the meeting, you ask John to stay in the conference room. After everyone has left,

the crucial confrontation begins: You: You missed our scheduled meeting today? Did you forget? John: No…I didn’t forget. You: Ok…then why didn’t you show up for the meeting if you didn’t forget? John: No reason…..well actually…..I don’t think the assignment you gave me is valuable

since I already have a good understanding of antimicrobial therapy. That assignmentshould be assigned to students, or maybe PGY1s, not PGY2 residents!

Interactive Scenario You (respond in a shocked and angry tone): That is

unacceptable….that is an unacceptable reason to miss ourscheduled meeting! I can’t believe you said that! This isunacceptable and unprofessional! In all of my years ofprecepting, I have never had a resident like you!

You walk out of the conference room upset, angry, headingto go talk with the residency program director and thedirector of pharmacy about John’s action.



Questions For You

Has anyone ever been in a situation like thisbefore?Is anyone willing to share how they

handled/would handle this crucialconfrontation based on the comments madeby the preceptor and the resident?

Interactive Scenario ‐ Preceptor You (the RPD) have noticed that one of your preceptors consistently

does not complete summative evaluations in a timely manner. Shegenerally precepts 4 residents a year. This past year, all of hersummative evaluations were completed greater than 7 days afterthe end of the learning experience. You met with this preceptor afew months ago to bring this to her attention and to discussstrategies for completing summative evaluations on time.Apparently, the strategies are not working.

You are upset and frustrated. However you know you must addressthis with the preceptor again.

Questions For You

Has anyone ever been in a situation like thisbefore?Is anyone willing to share how they

handled/would handle this crucialconfrontation?



It’s Time For a Crucial ConfrontationMissed commitments

• Pattern of missing deadlines Bad behavior

• Unprofessionalism, sarcasm, inappropriate tone Violated expectations

• Insubordination, submitting materials without review, staffing issues, licensure• Causes disappointment

Broken promises• Effort to improve = no positive outcomes• Continued patterns cause a lost in trust


Choose What and IfWHAT: the first time a problem comes up, talk about the original

problem or the content (what just happened)Think CPR

• Content, pattern, and relationshipIF: determine if you should bring up the issue

• Is it a broken promise, violated expectation, pattern of badbehavior, and missed commitments

Hint: If you don’t talk it out, you will act it out


Applicable Crucial Conversation Concepts

Master your storyLearn to lookMake it safe Seek mutual purpose and respectBreak the cycleSTATE my path




Master Your Story

What are the facts and problems that are making me feel this way?Is this a pattern? How does this impact your relationship?What are the consequences?Was this intentional?


Make It Safe

Start the confrontation by simplydescribing the gap between what wasexpected and what was observed

Monitor your tone of voice and facialexpressions


Additional Tips For The Crucial Confrontation

Start with the facts• What you saw and heard• Gather facts prior to the confrontation if

neededEnd with a simple diagnostic question• What happened?

Hear the other person’s point of viewListen carefully for the underlying cause




Make It MotivatingConsequences motivate• Let them know how a different behavior would yield

a better consequenceDo not use power to influence students, residents, or

preceptors• Damages relationships• Creates unsafe environments

Extrinsic rewards can confuse purpose


Natural ConsequencesConsequences make up the reasons behind all behaviorLink to existing valuesConnect short‐term benefits with long‐term painIntroduce the hidden victimsHold up a mirrorConnect to existing carrots and sticksStay in dialogue


Conclude With a Plan

Wrap up the conversation by making a planDetermine who does what and by whenThen set a follow‐up time




Discipline May Be Needed

Every organization has its own discipline steps and policiesBe consistentEncouraged to engage human resources as

appropriate

Let’s Practice With Your ScenarioSelect a real situation you currently faceFind a partner and decide who will go firstLet your partner know a small bit about the situation

and personPractice your opening statementPartner: provide feedback after the opening statementSwitch roles

What would be the ideal concept to apply during acrucial conversation if students, residents, orpreceptors feel disrespected even though youhaven’t done anything disrespectful?

ApologizeContrast to fix misunderstandingBoth A and B None of the above



Coercing others to your way of thinking, forcingyour views on others, or dominating theconversation are examples of

Masking (Silence)Labeling (Violence)Controlling (Violence) Avoiding (Silence)

When a student, resident, or preceptor isgetting emotional during a crucial conversation,a few concepts to apply are

Step out of the conversationBuild safetyStep back into the content All of the above

The single biggest problem in communication is the illusion that it has taken place. – George Bernard Shaw



Conversations That Count: Achieving Organizational Success Through Crucial Conversations and Crucial Confrontations

Stephen J. Davis, PharmD, MS, CPPSProgram Director, Health System Pharmacy Administration Residency

Texas Children’s HospitalHouston, TX



(856-L04) Conversations That Count: Achieving ...

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