WinterIHiver 1996 Volume 9, No. 4

Book Review I Renegotiating Health Care:

Resolving Conflict to Build Collaboration

Authors: Leonard J. Marcus with Barry C. Dom, Phyllis B. Kritek, Velvet G. Miller and Janice B. Wyat t San Francisco, California: Jossey-Bass Inc., 1995: 444 pp.

Reviewed by: Ene Underwood, Director of Strategic Alliances, The Toronto Hospital, Toronto

n today’s uncertain environment where it seems the role and relevance of every profession, every position, I and every institution are being questioned, it is hard

not to be attracted by a book titled, Renegotiating Health Care. As this review is being written, the government- appointed Health Services Realignment Commission in Ontario is in the process of a major province-wide review of hospitals that is bringing a whole new dimension to interhospital negotiation. At the same time, daily head- lines feature the progress of a provincial negotiating team working to reach resolution with the provinces’ physi- cians and avert unprecedented job action. Meanwhile, in every hospital, community health agency, and doctor’s office, conflict and negotiation over roles, expectations and past commitments have become a daily dynamic.

Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health, Renegotiating Health Care is a timely and welcome addition to the bookshelves of today’s health care leaders. Leonard J. Marcus has melded his own insights with those of a surgeon, a pro- fessor of nursing, a former CEO and a community health leader to create a unique resource book. The book com- bines theory of conflict and negotiation with general commentary on current health care dynamics, discipline- specific perspectives and practical advice.

Many readers will recognize several of the theoretical principles of conflict and negotiation from the well- known 1981 book, Getting to Yes by Roger Fisher and William Ury of the Harvard Negotiation Project. How- ever, what differentiates Renegotiating Health Cave from many of the generic publications on negotiation is its insightful assessment of the dynamics and nuances of today’s health care environment. This begins in the first chapter of the book with a thoughtful analysis of the mul- tiple factors that contribute to conflict in the health care settings. The three chapters devoted to negotiation from the perspective of the health care manager, the nurse and the physician, also provide important insights. Finally,

Authored by the founding director of the Program for

health care applications are highlighted throughout the book through a recurring story line of a fictitious Ameri- can hospital struggling with the budgetary demands imposed by an external HMO.

is based on ”interest-based negotiation” as promoted in Getting to Yes. Interest-based negotiation contrasts with the more traditional ”positional negotiation.” Whereas in the latter, the parties’ interests are viewed as exclusive of one another, in the former, the interests of the parties are viewed as interdependent. The negotiating parties are thus seen as collaborators seeking overlapping objectives rather than as opponents seeking to win each other over. Applied to health care, the authors have reframed the concept of interest-based negotiation as “whole image negotiation.” Whole in this sense refers to a view of the big picture and common purpose while image reflects the imagination to devise, discuss, test and implement new options. The authors contend that all participants in health care - funders, providers, patients, policy-makers - share a common interest or purpose, the promotion of health. Thus, whole image negotiation is espoused as a logical method within which this common interest and diverse perspectives can be productively united.

of this nature. However, three themes in particular will undoubtedly be appreciated by all readers. The first of these is the resonance of the principles of whole interest negotiation with the concept of integrated delivery sys- tems, which has now become common language among health care leaders. Chapter 7, “A Public Health and Health Policy Perspective” and Chapter 13, ”Crafting the Essentials,” most effectively capture this connection. The integrative approach to negotiation is in direct alignment with the notion of health care as a system that must be composed of interconnected parts. Moreover, the theoret- ical negotiating concept of ”reframing” applies to a world in which strategic questions are shifting from “How do we deliver patient care at a lower cost?” to

The approach to resolving conflict outlined in the book

Each reader will take something different out of a book

56 Healthcare Management FORUM

Volume 9, No. 4 Wintermher 1996

”How can we promote the health of the community?” Finally, whole image negotiation fits with the current cli- mate in which all health care stakeholders are being called to work together to redefine how care is delivered and find a new balance among services, staff and re- sources.

A second pervasive theme throughout the book is the concept of negotiation as a process, rather than a time- limited exchange. In many ways, the book is as much a discussion of ongoing communication strategies as it is of focused negotiation. Through concepts like defining pur- pose, setting the stage for negotiation, gathering informa- tion and managing expectations, the authors convey the image of whole image negotiation as a fluid, dynamic process. Initially, the inclusion of many of these concepts may seem out of place in a book focused on negotiation. However, the overall impact of their inclusion is a real- ization that whole image negotiation is necessarily much more than several parties sitting down at a table for a one-hour meeting.

Finally, Renegotiating Health Care provides an important insight into the role of health care managers in today’s environment of change. Having effectively argued for the increasing relevance of negotiation in today’s health care environment, the book implicitly argues that negotiation among the diversity of stakeholders may, indeed, be among the most important contributions health care managers can make. This concept is first proposed in Chapter 8, “Health Care Management: Balancing Clinical and Business Perspectives.” In this chapter, the manager is depicted as an integrator: ”While the manager is nei- ther physician, mechanic, accountant, nor patient care

representative, there must be enough comprehension and insight to guide these many functions so they translate into a well-run organization. The common theme is nego- tiation and conflict resolution: facilitating a process whereby these different jobs, people, and responsibilities are effectively balanced into a coordinated system.”

At more than four hundred pages, Renegotiating Health Care is a weighty read. Arguably, it could be criticized for being longer than required. Some readers may find the embedded story-line distracting. Others may find the book occasionally disjointed due to the swings in focus between negotiation at the micro level of day-to-day hos- pital interactions to negotiation at the macro level of sys- tem policy. Individuals who read the book in search of practical insights on negotiation between organizations will likely be disappointed. The book‘s theoretical con- cepts of negotiation will provide some useful insights. However, the book provides little practical guidance on how to address the challenges of building new organiza- tional alliances in a restructured health care system.

Notwithstanding these considerations, a number of readers will find the book of great benefit. Students and newcomers to health care will find the insights on the practical dynamics of the health care environment particularly helpful. Health care leaders seeking new approaches to help their organizations cope with rapid change will find the book of benefit. Physicians and nurses will find the targeted chapters on negotiation within their professions to be thought-provoking. All in all, the book makes a solid contribution to the concepts of health care negotiation at a time when such guidance is urgently sought.

FORUM Gestion des soins de santC 57