Last month I wrote on the break-up of many parts of the health care system as we know it. As this happens it inevitably puts stress into the system, and that produces conflict. The level of change, the stakes involved, and some of our own unique health care pathology all contribute to the ways in which conflict is handled or ignored. Addressing this conflict in a proactive and informed manner is one of the essentials of successful leadership in health care and will be into the coming decade. Without the skills to successfully manage and at times creatively build on and use conflict, there is little hope that the fanciful plans for redesign will come to much.

Conflict arises in any situation where an individual's goals, concerns, desires, and even style differ from another person's. The health care environment is rife with just such tension. Of course there are the divides created by the various silos - in-patient and ambulatory, nurse and physician, specialist and generalist, professional and patient, and clinician and administrator - just to name a few. Each of these domains has its own success rules, traditions, power structures, ways of resolving problems, values, and even vocabulary. Add to this division the reality that there is little to pull together a common perspective or orientation, and it is little wonder that conflicts bubble up daily in our world. There has always been concern for the elevated stakes of dealing with human lives, but to this are added a host of new mandates from saving 100,000 lives, to pay-for-performance, new quality tools, tighter budgets and the reality that little in the way of new resources will be funneled to health care in the future. All of this creates a powder keg that, when it explodes, contributes to shaping a culture that is unable to proactively build a supportive and high-performing work environment.

To address this situation leaders don't need to resolve conflict as much as they need to create environments in which competition can be creative and produce the best possible outcomes, where conflicts are seen as inevitable given our highly interdependent and diverse world, and the skills to manage conflicts small and large are widely distributed throughout the workforce. There are four steps to managing conflict; each one an essential part of resolving a particular conflict and slowly building a culture which can support the creative tension needed to be a high performing organization.

First every manager and leader must look for and build common ground. Without such a purchase there simply will not be enough shared footing to manage the conflict at hand much less build the broader type of culture needed to sustain creative conflict. This job often involves stating the obvious and being the advocate for what everyone should know. But the reality is if everyone had this perspective, many of the conflicts we experience would never occur. The common ground might be the commitment to a research undertaking, the quality of patient care, or the successful completion of a project. It might as easily be the smooth working of a team or harmony of the work environment. Sometimes the common ground is nothing more than identifying what one individual holds as valuable, which can only be achieved by the successful working of the team or perhaps even one individual's success. If that is all there is then that is what an effective leader will figure out how to promote. The common ground gives us a reason to look beyond our differences and keeps us engaged for the next step, which is difficult.

This next step is acknowledging emotions and separating them from the problem solving process. You know when you have crossed the emotional frontier in a conflict situation when your body responds with a reddened face, queasy stomach, or headache. If the visceral is not involved the situation is probably not a conflict situation. Once you have this clue it is important to send yourself a message that the emotional reaction needs to be understood, given its due and dismissed from the problem solving process. A good way to start doing this is to ask some questions. First, why am I reacting this way? Have I been rejected here? Do I feel attacked? Am I afraid? Is there some past issue that is resurfacing in this new context? All good questions to ask for understanding why there is an emotional response being triggered. Next you will need to have the person who is involved in the conflict with you also get a line on his or her emotions. The worst way to do this is tell them what they "must be feeling" and why. The best way is to share your emotional reaction and why you think it was triggered, without blaming them for the triggering. You do not have to deal with all of the emotional issues in the immediate context, but both sides have to understand what they are bringing to the conflict and be willing to let it go, if only for a short time.

When you have perspective from both sides on emotions, then it is time to solve the problem. Without fixing blame, which will return you to the emotion box, decide the answers to these questions: What was the shared goal? Why did we go wrong? What can be altered to address this situation and what is needed to move forward? This may mean different attitudes, suspending judgments from the past, new skills, or perhaps new resources. It may also involve changing some of the accepted and revered ways of doing work, particularly in clinical settings. Be as creative as possible, brainstorming is much easier work without the baggage of some misplaced emotions. Then choose a course of action.

The final step is to put the plan in writing. Not every detail is essential, but it should be recorded so that all can see what you have collectively agreed to. This may take a re-write or two, but that is an important part of the process. The details should address actions to be taken, behaviors that will be exhibited, and accountabilities to each other. If this step is missed, the good work will be lost. Whoever is involved in this should check-in during the first week in a formal sit down meeting. The agenda should be the assessment of how the work is going. It creates a great context to practice giving non-judgmental feedback. Be sure and celebrate success and think about how to spread the skills to others in the organization.

Competition in health care will be keen in the coming years. Organizations that can thrive on constructive conflict and push themselves to higher levels of performance will dominate those that remain mired in the destructive conflicts that have been so much a part of the health care world.