1. Salcido, Richard MD

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Is wound care a place or a concept? Well, that depends on whom you ask. Years ago, I remember being part of a multidisciplinary group who ostensibly was at the table to discuss its vision for the establishment of a comprehensive, state-of-the art, one-stop shopping, wound care center in an academic medical center (we'll call it St Elsewhere): What an opportunity!

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As the group met for the first time, the excitement, collaborative spirit, and anticipation of the future possibilities were palpable in the air of this otherwise inanimate conference room. Members of this companionable and compassionate group of wound care practitioners one by one eagerly awaited their specific turn to present their "What if money wasn't an object?" scenario. Nurses, plastic surgeons, business administrators, and the enterostomal therapist, physical therapist, occupational therapist, podiatrist, and physiatrist all agreed on the vision and mission. The implied question on the table, however, "Is wound care a place or a concept?" became increasingly important. What we could not agree on were the questions of who would be in charge, where the money would go, who would be hired and fired, and where the clinic would be housed.


To the plastic surgeons, wound care was definitely a place-a clinic in their office suite where the rest of us could provide "ancillary" services. To the nurse/wound care specialists, wound care was a clinical space where they could see wound care patients and refer them, if needed, to the appropriate specialist. To the physical therapists, it was their clinic. By now, you know the rest of the story[horizontal ellipsis]-posturing, positioning, and sheer will took over the room. The players at the table were empowered by institutional policies, procedures, and politics to envision, institute, and put into operation a wound care center that focused on patient-care service delivery. In other words, we were tacitly instructed to place the patient at the top of the organizational chart and work everything out to make that happen. Sadly, the players were unable to inspire or capture the imagination of the institutional leadership to invest in a "virtual transdisciplinary wound-care program." Why then, you may ask, do such professionally capable individuals walk away from an opportunity because they lack the imagination to think and act in a collaborative way?


Compromise or Collapse

Although there are typically many reasons why negotiations fail or break down, some can be attributed to just common pitfalls in interpersonal and organizational dynamics, such as "positional bargaining," egocentric leadership, or just plain failures in communication. One of my sage mentors had an aphorism about this territorial prenegotiation posturing: "Well, you don't have anything at this point, so arguing about 50% of nothing leaves you with nothing!" Negotiation is about development of a common vision that expands the pie for everyone and creates a win-win situation. In business negotiations, the results may produce a winner or loser, but oftentimes, everyone leaves the negotiation with small individual wins. Such wins, within themselves, are not negotiable; in other words, the players hold a small amount of nothing unless they collectively combine their interests to the betterment of the common goal.


In the wound care arena, we all have the same goals for our patients-our primary customers. We want hassle-free access to health care, quality care, good outcomes, minimal or no wound recidivism, and cost-effective care. This is certainly an altruistic and laudatory goal, albeit sometimes a distant vision unless we can come to the table to share a vision and execute it in a highly constructive way. Lack of collaboration, cooperation, and productivity, however, caused a wound care center for St Elsewhere to move down the list in the organizational queue. Most institutions are not motivated to invest in the "my way or the highway" mentality.


Conflict Resolution

I met two of my early mentors in conflict resolution and negotiation, Barry G. Dorn, MD, and Leonard J. Marcus, PhD, coauthors of Renegotiating Health Care: Resolving Conflict to Build Collaboration, while attending the basic and advanced courses in the Program for Health Care Negotiation and Conflict Resolution at the Harvard School for Public Health in Boston, MA. They made a profound impression on me. Over the years, I have consulted with them occasionally on various issues regarding challenges in implementing thought and content. They have constructed the hypothesis that the concept of asking good questions in the art of negotiation opens up possibilities for active listening and learning. They divide the concept of asking questions that enhance negotiation in a given trajectory as follows:


* Big-picture questions: What common purpose brings us together?


* Problems questions: Do you think the way our work is now constructed is achieving the results we desire?


* Open-thinking questions: It seems that we have tried everything. What haven't we tried?


* People questions: Who will be affected by this decision, and how can we consider the implications for them? What do the key stakeholders think on this issue, what motivates them, and what outcomes would satisfy them?



After the aforementioned questions are satisfied, we need to pose more queries. Dorn and Marcus categorize these as consequence questions, history questions, and process, clarification, and feeling questions. Questions and the way you frame them actually define you-you are the message or you are the question. "In the minds of others, a naive and uninformed question could demonstrate that, as a negotiator, you bear the same qualities as your question," wrote Dorn and Marcus.


The art of negotiation is a composite of several skills, some of which either are innate or learned to the individual or even the organization. Such skills include active listening, creativity, expanding the opportunities, giving up control, tact and diplomacy, and asking good questions. In the scenario of St Elsewhere and its failure to move the wound care center beyond positional bargaining, perhaps the set of questions as outlined by Dorn and Marcus would have been apropos. Of the options on the table, what would you and your group be willing to accept? What would you be willing to try? Would you be willing to share the risk with us to invest in a project that could provide us both with significant strategic advantage?


In the art of negotiation, the first important part is planning, the second most important part is planning, and the third most important part is planning. However, like battle plans, they often are thrown out the window after the first bullet is fired. Moreover, when you are dealing with professionals who have strong wills and egos to back them up, it is extremely difficult to have rational and constructive progress.


The Bottom Line

I urge anyone involved in negotiating for a wound care center at his or her facility to listen to all the players and not to squander this important opportunity. In my experience, if we put the patient and the organization first, we are able to see light where there was once darkness.


Richard "Sal" Salcido, MD

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Suggested Readings


Ailes R. You Are the Message. New York, NY: Doubleday Business; 1989.


Dorn BC, Marcus LJ. Gathering information by asking the good questions. In: Professional Issues Commentary. AMNews contributors. March 13, 2000.


Dorn BC, Marcus LJ, Kritek PB, Miller VG, Wyatt JB. Renegotiating Health Care: Resolving Conflict to Build Collaboration. Hoboken, NJ: Jossey-Bass; 1995.


Dorn BC, Marcus LJ. The complexities of good questions. Commentary. AMNews contributors. May 8, 2000.


Fisher R, Ury W, Patton B. Getting to Yes: Negotiating Agreement Without Giving In. New York, NY: Penguin; 1991.