PRINCIPLES OF PROBLEM SOLVING in HEALTH CARE ORGANIZATIONS
Problem solving does not mean that there must be something “wrong.” It is a process by which the administrator can review any existing system or situation and determine if it is as desired. If it is not as desired or there is a desire or requirement to do an assessment or review, then problem solving serves as the reasoning “processor” for developing alternatives to the status quo. Because it is a process that emphasizes the value of objectivity, it permits the administrator who uses it to escape her/his own personal biases and preconceived notions and solutions and leads the executive to derived decisions and solutions that can be implemented successfully.
Though at first glance problem-solving techniques and methods may appear to be easy to master and barely worthy of study, it must be emphasized that they are both complex and difficult. Both the complexity and difficulty factors, however, are well worth enduring for the potential values that are inherent in these methods in day-to-day, practical administrative activities. Once the student has gained an understanding of the process and has first experimented with and then practiced the actual techniques, ample rewards will be found in their contribution to his/her total armamentarium of administrative skills.
Further, practicing administrators who have spent several years refining and using these problem-solving methods have found that the complexity, in time, seems to disappear. Many definitions and terms, which at first are rather uncomfortable and unwieldy come to be internalized; the practicing executive actually finds her/himself thinking in these terms and using these definitions in actual real world communications. The executive uses them while thinking, talking, or writing. S/he becomes so comfortable with the process that s/he uses it naturally, sometimes without even realizing s/he is doing so.
Glossary of Problem Solving Terms
• Situation: The specific combination of difficulties that is to be corrected by administrative decision and action.
• Difficulty: A set of facts and opinions which describe or imply a gap, or difference, between what the situation is, and what it ought to be.
• Problem Area: A difficulty (rarely one), or a group of interrelated difficulties that identify an important focus for problem solving.
• Issue (Within Problem Area): A substantively debatable point of controversy, in a question form that best states the decision, which needs to be made to correct the difficulties. Begin with “how can, how should or how must”. One uses the issue statements across the problem areas to arrive at the overall priority of issues.
• Problem List: A list of issues that has been placed in priority for decision.
• The Problem Statement: A question with words and phrases that summarizes the issues of each problem area in a single sentence. Begins with “How can, how should, or how must”. The problem statement summarizes the problem list completely, cogently, and concisely, including who needs to be satisfied by the solution. It also takes into account any interrelationships in issues that may exist between the problem areas.
1.0 Problem definition and need for planning
The first phase of the problem solving process involves problem identification. It seems obvious that one must identify the problem before it can be solved. In actuality, few managers are skilled in the process of problem identification, and fewer still consciously insert a problem identification stage into the decision making process whether it be their own or that of a group. Evidence of this contention can be fairly easily observed in group or committee meetings when both observers and participants notice that different problems are discussed at the same time. “Exactly what is the problem we are discussing here?” is often heard when a committee gets bogged down.
Not clearly identifying the problem is especially dangerous in individual rather than group decision-making. A rational, disciplined thought process is needed in either case, but is especially critical when there are no others present to ensure that no invalid assumptions about the nature of the problem are being made. Problem identification is probably the most important phase in any problem solving process; it is also often the most difficult and most often neglected.
1.1 Obtain initial description of the situation
You can’t correct a situation that hasn’t been defined, and you can’t define the real problem to be corrected if you can’t first accurately describe the situation. The purpose of describing the situation is to obtain clarity in the difficulties to be corrected, including the causes of the difficulties.
The description of the situation is essentially that set of FACTS and OPINIONS derived by conversation, interview, memorandum, report, data or hearsay that relate to the question being addressed. It may be a combination of various items received from various sources of information, it may be a one-sentence message received over the telephone. By obtaining all pertinent opinions and facts, the need for administrative action is accurately documented.
How do you try to ensure that you obtain an accurate description of the situation that needs correcting? You generally start by asking the person who is giving you the assignment to give you his/her opinions on the situation and who else should be interviewed. You then obtain the opinions of the others you interview and ask them who else in the organization should also be interviewed. This process of obtaining relevant facts and opinions through “snowball” interviews helps you:
1. Identify the various stakeholders relevant to the situation. For each stakeholder, pretend you are that stakeholder and ask yourself how this stakeholder would describe the situation. How is this description different from that of the other stakeholders? This role-playing helps you view the situation from the different lenses of the various stakeholders.
2. Identify the goals, objectives, and standards, which aren’t being achieved or maintained as perceived by the various stakeholders.
3. Determine whether there is an absence of agreement on appropriate goals, objectives, and standards among the stakeholders, or a disagreement on their priority.
4. Gain insights into existing or potential interpersonal conflict among the stakeholders, including whether you are part of the problem.
5. Describe the difficulties in the situation, which are perceived as needing correction by stakeholders and others.
6. Gain initial information on the relative priority of the difficulties needing correction, the timeframe in which they must be corrected, and the resources available to correct them.
7. Identify potential causes of the difficulties.
8. Identify preliminary “solutions” to the “problems” as perceived by the stakeholders and others, including what should be done by whom, when, where, how and why.
Common errors in obtaining an accurate description of the situation include:
1. Excluding important opinions or facts of the situation, or conversely, including parameters which should be ignored if the problem is to be defined appropriately. Pay particular attention to the items you end up defining as difficulties. These are the facts and opinions that in combination are “the problem.”
2. Assuming that the opinions gathered are facts. Be sure to try to separate fact from opinion by cross checking against others’ opinions and empirical data. Stakeholders often frame problems in terms of preferred solutions (for example, we need more staff). When this occurs you must dig to find out why the stakeholder holds this view to arrive at the true underlying difficulties.
3. Accepting potential alternative solutions identified by stakeholders and other key informants as the only possible alternatives. Listen to what the key informants and stakeholders say regarding potential alternative solutions, but you must use your judgment during the problem solving process to arrive at logical, well-reasoned, unique alternatives that are acceptable to the final decision maker and implementable by those who will need to implement the solution.
1.2 Identify the scope of work
The scope of work is that portion of the overall situation that is to be addressed now. The scope must be clear in terms of breadth and depth. In many cases, it will be impossible immediately to address all of the difficulties in a given situation. The insertion of this step allows the administrator to pause and make a conscious decision to include or eliminate parts of the situation for consideration. Be sure you have a clear understanding from the person who gave you the assignment regarding his or her expectation of the appropriate scope of work, and that you have written down exactly what is being asked of you, to avoid falling into an expectation gap.
In working with your case try to answer the following questions:
What is being asked of you? Does the situation involve a preponderance of short-term or long-term issues? Does this situation involve mostly operational, strategic, financial, policy, or some other type of issues?
With whom should you have consulted within the time frame you are given to solve the problem? Now write a 3 to 4 sentence paragraph that succinctly summarizes the case so that anyone reading your summary would understand what the case is about without having to read the case.
1.3 List the difficulties and group into problem areas
At this point the problem identification process begins to take on additional form. The description of the situation should be examined. Facts and opinions individually or collectively will produce difficulties, that is, a difference between what is and what ought to be. The differences between “what is” (the situation at hand) and the goals, objectives, and standards to be achieved (what ought to be) are the difficulties to be addressed through the problem solving process.
To better define what is to be corrected or improved, the problem solver should ask:
• What are the precise difficulties needing correction or improvement? Are they validated by opinion and empirical evidence?
• Which are the more significant difficulties?
• What organizational purposes, goals, objectives, standards, values, or customer needs and expectations are NOT being met?
• How should these difficulties be grouped into manageable problem areas on the basis of their commonalities (e.g. common subjects, causes or goals?)
A cluster or group of related difficulties is termed a problem area. In any given situation, there may be from one to a dozen problem areas, depending on how specifically the areas need to be defined. The number of problem areas to be used is based on personal judgment. The areas should be specific enough to ensure that all difficulties are being addressed, but broad enough to provide smooth uncluttered flow of the thought process. The problem solver is trying to develop a classification scheme for “organizing” miscellaneous facts and opinions into meaningful related problem area “compartments”. This makes the problem solving process manageable by breaking the problem into mutually exclusive problem areas that can be solved semi-independently of the other problem areas. This doesn’t mean they are completely independent.
But how does the problem solver develop “meaningful” problem areas? One can organize difficulties based on a common subject, for example, financial vs. strategic issues. Or, one can group difficulties based on an objective or set of objectives identified by stakeholders that relate in common to that set of difficulties. Or, a logical grouping of difficulties may relate to a common root cause, which if eliminated, would rid the organization of that whole set of difficulties. Stating an objective for each problem area allows the problem solver to consider what it is that needs to be accomplished, and provides a clearer picture of the importance and nature of the difficulties for each problem area.
In working with your case, the following will help you list difficulties and group them into problem areas:
1. As you read the case ask yourself: “What are the differences between what is and what out to be?”
2. Write the list of difficulties on a separate sheet of paper or a whiteboard. Look at each difficulty and try to identify commonalities. How are they related by goals or objectives, by subject, by common potential root cause? How do they differ? These comparisons help determine the likely problem areas.
3. Arrive at a final grouping of difficulties, and label the groups. These become your problem areas.
You should now have all your difficulties grouped into problem areas that you have named.
1.4 Identify issues within problem areas
The issue for each problem area should be defined. The purpose of this is to provide guidance as to what must be studied to find the best acceptable solution. The issue is a substantively debatable point of controversy which best states in question form the decision to be made to correct the set of difficulties in a problem area. These questions are to begin with terms like “How should, How would, How can,” etc. Stating issues clearly and succinctly is critical to the problem solving process.
A well-stated issue needs to set out the point of controversy in the problem area. The issue also needs to lead one into an action-oriented mode of thinking, rather than merely asking a rhetorical or esoteric question. The words “how can and how should” are most often the key words in the question which forms the issue. For instance,
“How can a hospital, in an environment of limited geographic attraction, labor shortages, and financial constraints, achieve the necessary level of nursing staffing?” An issue statement should never contain a solution. Note above that the issue statement is not “How can we hire more nurses?” An issue statement stated in this manner would prematurely close off other alternative solutions that may be available, such as reducing admissions, devising new staffing schedules, shifting tasks that don’t need to be performed by nurses to other personnel, etc.
Finally, a decision must be made as to whether there is a logical ordering to the issues. The “central issue” is derived by, ordering the priority of “issues” across the problem areas. The central issue is the “first” in this list; the one that is key to resolving the others. Another way to determine the “central issue” is: if the other issues are resolved but the “central issue” is not, then the problem is no nearer solution than not resolving the other issues. It is analogous to the “cause” of a medical problem. Sometimes the real issue can’t be eliminated or solved but it must still be addressed. This naturally leads to a priority listing and should trigger the thinking of where this problem fits in the organization’s strategic mission.
By the conclusion of this step, the problem solver should have developed an issue statement for each problem area, identified which issues are short and long term, the order of importance of the issues to the organization, and the priority for study. The priority for study may be different from the order of importance of the issues depending on the time available, the immediate needs of the organization, etc.
1.5 State the problem
The culmination of the preceding steps is the problem statement, which summarizes the problem list completely, cogently, and concisely, including the stakeholders who need to be satisfied by the solution. The problem statement is a combination of the issues, stated as succinctly and concisely as possible, yet thorough enough to cover all aspects of the problem. Thus, the problem statement should include not only the issues, but also the objectively defined goals and the relevant stakeholders. Here one begins to appreciate the skill and importance of the problem statement. A problem stated too simply does not weigh all factors needing consideration. However, a problem stated at great length and in too much detail, will confuse and clutter the issues. The most skillful managers are often those who can arrive at, or lead a group to a well-thought-out, mutually agreeable problem statement generally beginning with the words “How can” or “How should”.
The purpose for writing a statement of the problem is to enable the problem solver to step back from the individual issues and consider them now in their interrelationship to each other. This synthesis is crucial because it may identify that the critical issue may be found between problem areas. For example, one set of difficulties may deal with an issue of how to best achieve cost constraint, while a second set of difficulties leads to an issue of how to best increase accessibility of service. In combination, the most critical issue facing the organization may be how to best resolve both problem areas at the same time, i.e., “How can we increase accessibility of services in this situation while also constraining costs?” The problem statement should capture these interrelationships.
The problem statement should also help the problem solver answer the question: “What’s really the problem here – what is the critical issue we are trying to answer in this situation?” Then the problem solver should ask him or herself: “If I solve this problem, will I correct the situation? Am I on the right track?
2.0 Problem Study
The second phase of the problem solving process involves the Problem Study. It is logical that the problem study phase follows problem definition and precedes formulation of recommendations. At this point interviews are conducted around specific issues, additional facts and opinions are gathered, research is done and relevant standards are applied. The end product of the problem study is a set of findings from which conclusions can be drawn and recommendations can be made.
2.1 Identify Root Causes of the Difficulties
The first step in the study of the problem involves defining the root causes of the significant difficulties in each problem area. This step asks the problem solver to get back to the details that were previously combined into the issue statements and then the statement of the problem. Identification of the possible root causes begins during the initial interviewing and other data gathering that produced the original description of the problem. It will continue during the data collection and analysis steps in the problem study. However, at this stage in the problem solving thought process, it is valuable to identify, insofar as possible, the causes of the difficulties.
Understanding the root causes leads to the development of alternative solutions to eliminate, avoid, or modify them, thus correcting or improving the difficulties they are causing. The problem solver should ask “Why?” each difficulty exists to uncover possible causes. A rule of thumb is to ask “Why?” at least four times, probing more deeply each time to be sure the underlying root causes are effectively identified.
Some other important questions to ask when probing for root causes include:
• Why do the difficulties exist? e.g. Are difficulties occurring under some circumstances and not others?
• What do key customers and stakeholders believe the causes to be? One can often infer causes from their preferred solutions.
• What is the real reason for the variance from standards and objectives? Identifying root causes can be aided by understanding that difficulties often arise because of systemic problems in any organization.
Not questioning and analyzing root causes is one of the fundamental errors made in this step of the process. This error will lead you to solve the wrong problem by addressing symptoms without fixing the real cause of the problem. Beware of difficulties that are stated as solutions by stakeholders (i.e. “the problem is we need more staff”). You must question and analyze, digging further down into successive levels of why a difficulty exists to get to the root cause. This will lead you to the second, third, and fourth order cause for that difficulty. Never assume the first cause you identify for a difficulty is the root cause. This process is critical to making a judgment as to what the real problem is.
2.2 Identify Alternative Solutions
It is now worthwhile to list possible solutions to the problem under consideration in relation to the root causes of the problem. This will help you to evaluate the impact of various approaches to solving the problem. Alternative solutions are different possible answers to the “how” part of the questions posed in the issue statements. The word “alternative” asks the problem solver to “never assume” and to continue to search for more solutions. This search for alternatives began when opinions were collected earlier in the process of describing the situation. The problem solver must not rely on opinions of others in identifying alternatives, however, but must have the courage, imagination, and creativity to arrive at novel alternatives.
Don’t assume at the outset that the wildest solution cannot be done, and don’t worry at this step as to what is the “best” or “best acceptable” solution. One shouldn’t think in terms of “right” or “wrong” solutions, only alternatives. Brainstorming, being creative, imaginative and innovative, conducting research, asking experts and developing possibilities are all useful in order to generate alternative solutions. A useful way to think of alternative solutions is to view them as different possible answers to the, “how” part of the questions posed in the issue statements. In this sense, the process ties together into a logical flow.
Once you develop your preliminary alternatives, the problem solver should ask:
1. Do the alternative solutions creatively stretch the limits of what’s “possible” rather than just including only those that are “feasible”?
2. Have alternative solutions been established for each of the problem areas in the problem statement, are they comprehensive, do they provide substantive solutions?
3. Do the alternatives include those favored by all who have the “right to decide” on the acceptability of a plan? Do they anticipate those favored by those who may significantly influence the decision?
4. Look back at your stakeholder analysis and develop alternative solutions for each stakeholder. As you do that, do the potential root causes change?
The alternatives should be action oriented, as opposed to process oriented. Alternative solutions don’t need to be mutually exclusive. Your final recommendation may in fact be a combination of alternatives.