Director’s Corner: It’s Not Just a Cup of Coffee

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Insightful feedback can be achieved in non-formal settings.

Tweetable: There are a variety of minor performance issues that need to be addressed, and usually a more casual technique may be appropriate.

Dear Director,


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Although I’ve been a director for a while, I’m looking for ways to soften my tone when it comes to giving feedback to my docs. I often find that calling someone into my office for a “minor” issue, can be very intimidating to them.  Do you have any suggestions?

One of the hardest things we do is to provide feedback to a colleague.  Many of our ED colleagues are friends, yet as the medical director, our job is to coach, mentor and provide feedback. Most of us don’t get any formal training in how to provide feedback and coach prior to becoming a medical director yet having just a few providers performing at a substandard level can negatively impact your entire team.

The “cup of coffee” conversation is a key tool for the medical director to master and use.  It’s designed to be less formal and intimidating than meeting with someone in your office while discussing an issue.  While we’ve had coffee with people for years, the technique was initially developed by Vanderbilt University as a tool to promote professionalism among physicians and to be used with disruptive physicians.  Other academic centers used the concept with many training peers on how to conduct these brief, focused sessions while addressing a key issue.


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Background

The Arizona College of Medicine reports that 72%— 78% of physicians will never have an incident that will require counseling and 20%—25% of providers will have a single incident that resolves with a cup of coffee conversation. Only a small percentage of physicians will require further intervention.  In the traditional academic model, the message is generally delivered by a peer as an informal conversation with the purpose of raising awareness.

These conversations generally last three- to five-minutes, with the purpose of the peer to raise awareness, rather than to advise or counsel. The cup of coffee conversation was developed to address a single issue or observation, such as witnessing someone not using gel before and after going into a room or after a poor interaction with a nurse or colleague. The cup of coffee allows you to state your observations and how it may be perceived or that it’s not part of our culture, and then take a sip of coffee for a dramatic pause to allow the individual to respond.  Having a peer do this makes it much more informal than meeting with the chair, and it’s used to promote awareness of a negative behavior.

The Community ED


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In most community EDs, the chair or director will be providing feedback to the docs for big and small issues and can take advantage of the “cup of coffee” technique. There are a variety of minor performance issues that need to be addressed, and usually a more casual technique may be appropriate.  Examples include someone who shows up late to work, uses foul language in the department or stops seeing patients too early before the end of the shift.  As a first pass, bringing awareness to the situation with a brief, non-confrontational discussion is likely to resolve the issue. Keep in mind that if the behavior continues after this intervention, a more formal discussion needs to happen.

For any difficult meeting, and especially when I’m uncomfortable in the role I’ll need to play, I find it helpful to have an outline and a script.  Here’s a great script I’ve borrowed from Dr. Wolf Schynoll, my company’s chief performance officer, who went through the formal training at Vanderbilt. The conversation really has four parts.Invitation:

“I need a minute to talk with you privately.”

Express appreciation:

“You are a valued member of the team, which is why I came to you.”

State the issue and invite their response:

“I saw/heard something I don’t understand: (fill in the offensive act/behavior). This is not consistent with what I know of you as a professional. Help me understand what was

going on.”

Raise awareness, summarize and conclude:

“I just wanted to raise your awareness of the situation.  We can certainly discuss this in

more detail at a later time if you want to.  Thanks for your time.”

You can see how easily this would work for an initial feedback intervention.  You can imagine that some of our docs will be dismissive or deny their role in any problem, but part of the key is that once you summarize, the meeting is really over. It’s about raising awareness and then expecting the doc to act professionally going forward. And it works most of the time. Sometimes the doc will want additional advice or coaching, and it’s okay to give it – but the purpose of this brief meeting is really to raise awareness.

One Step Further

Our hospital medical executive committee has gone to medical leadership training course a couple of times over the last several years.  Being in Florida with a group of colleagues and friends is pretty good, but the course is actually excellent.  The teaching in this course was to use the cup of coffee as a non-confrontational environment to have a difficult conversation, though still typically based on an observation of an undesirable behavior.  For instance, the president of the medical staff may meet with someone to discuss a particularly negative interaction with a colleague or a nurse.  Keep in mind, the interaction has to be really egregious to bypass the chair and reach the president of the medical staff.

Although these conversations are longer and more intense than the standard brief ones to raise awareness, they serve the purpose of having a conversation with a colleague that is less intense than meeting in an office across a desk from each other.  No one liked being called to the principal’s office when we were younger, and in the interest of collegiality and performance improvement, lowering the intensity of an initial meeting, can help the physician be open to feedback.  Awareness alone can often help with self regulation of their future behavior.

My approach

There’s a variety of things that cross my desk where I need to provide feedback to my team.  Many of these are minor, ranging from an order being entered incorrectly into the EMR to a minor complaint from a patient.  There are also cases and dispositions that need discussion and occasionally a behavior issue.  I am a huge fan of the brief, awareness-raising conversation.

Sometimes these take place over coffee. Sometimes they take place over graham crackers in the patient snack storage area, but I stick to the talking points—make sure the doc has time, invite them to a private area for brief chat, let them know I appreciate them, state the issue, and thank them for their time.  I’ll use my office from time to time as well, as it allows for more time, less interruptions, or just an opportunity to chat once the first issue has been discussed.

For most minor issues, I’ll try to catch the doc during a shift.  I’ll usually let them know that I need to touch base with them about something and they can let me know when they have five minutes.  If it’s a major issue or will need more time, I’ll talk to them after the shift. Although I’ll occasionally discuss issues with docs before shifts, if there’s anything that could impact their mood, I won’t do it before or during a shift.  For these significant conversations, I’ll meet with them on a non-clinical day or after a shift.

Afterwards, you’ll never go wrong by documenting the conversation.  Although not every conversation needs formal documentation, it is the best way to track behavioral issues and gives you the baseline documentation you need before elevating the process from a cup of coffee to remediation or a performance improvement plan. Documentation basics include the date of the conversation, a description of the incident or behavior, and the recipient’s response.  If action items were discussed, these should be included as well as any other pertinent details.

For lack of a better term, for documentation to be “official,” it must be sent to your HR team. This can get done via email, snail mail or even an online form if your group/hospital has the IT technology.  I usually type up a recap in a word document and file it electronically and also print a copy to include with the paper documents in the employee’s file in my office.  Although not all of these will end up in the file that the medical staff office uses for credentialing, many complaints/issues are tracked through the hospital system and become part of the file for credentialing purposes.

When you need more than a cup of coffee

About 3%—5% of our providers will require more than collegial intervention or an awareness conversation.  This may be for not changing behavior after a brief discussion (still coming in late or continuing to have poor interactions with staff).  I’ll schedule these in advance, usually inviting the provider by email.  My other rule of thumb for meetings in my office is when I’ll need to use my computer to discuss data (low performers) or review a case.  These can be intense and detail oriented conversations that are best held in a private office.

Summary

Providing feedback is part of the job of the medical director but isn’t something most of us have training in.  The “cup of coffee” conversation is a critical tool that can successfully address most behavioral observations.

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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