How to be a better problem solver

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Every day, we are confronted by problems that need solving. The problem might present itself simply as a minor inconvenience, or the problem may be a significant variance from ideal clinical practices. Whatever challenges your organization faces, effective problem-solving skills are needed to deal with the issues. A problem represents a gap between the actual and the desired. If case managers are to be effective problem solvers, they must first thoroughly understand the present situation and the goals of the problem-solving activity.

Sometimes, the goals are not clear. Do physicians and case managers appear to have conflicting goals? Do they end up defining problems differently? Do these conflicts lead to miscommunications? If problem solving is to be effective, the goals of all stakeholders must be aligned. This perception of conflicting goals often is caused by misunderstandings. For example, consider the process of utilization review. At the highest level, everyone’s goal — physicians, case managers, and staff members — is to accurately and thoroughly document the patient’s current condition and treatment plan.

But let’s look at a different level. What is the goal of the attending physician? What is the goal of the case manager? At this next level, the physician’s goal may be to spend as little time as possible documenting in the patient’s record. The case manager’s goal is to find out as many details as possible about the patient’s condition and treatment in order to evaluate the appropriateness of admission and continued stay. The attending physician and the case manager, at this next level, may have conflicting goals: minimize the amount of record documentation and encourage very detailed record documentation. Although at the highest level, both the physicians and the case managers have the same goal, individual goals may conflict. When solving problems, always consider the individual goals within the context of the overall goal. If individual goals are not aligned to the overall goal conflict, will occur during the problem-solving process.

A clear problem definition can help overcome apparent conflicts in goals. Every problem, incident, opportunity, or project should be defined within the context of the overall goals. A clear problem definition helps to get everyone "on the same page." It improves the understanding of what is important to everyone — a crucial step toward preventing problems from occurring.

Here are the important elements of problem definition:

What. Asking, "What is the problem?" can generate everything from a common response to a variety of answers from a group. By asking, "What is the problem?" you can begin to clarify the gap between desired and the actual you are trying to prevent. People will respond from their individual points of view, which may or may not reflect how your case managers see the problem. If the individual views of the problem are diverse, you actually may be facing several separate problems. It’s best to find out quickly if multiple problems exist.

When. There are two components to this element. The first part is the date or time. Sometimes, it may be important to know exactly which step in the process is problematic, or it may be sufficient to simply state "in the evening" — it depends on the nature of the problem. The second part concerns the contextual factors associated with the problem. For instance, did the problem occur when you used a new computer program for the first time? Did the problem occur the first time a person performed the task or used the equipment? Understanding the causal factors may provide important information as you begin to analyze the causes. At this point in the problem definition, you don’t know whether the causal factors are important, but you still need to identify them.

Where. This element refers to the physical or process location of the problem. Start with the higher levels of the system and then work down. For example, radiology reports may be slow to be filed in records of hospitalized patients. However, does this happen on every nursing unit? The problem unit or units then are identified. Does it occur only when patient records are stored in a particular location on the nursing unit? A systems approach helps you to discover physical locations that accurately reflect the actual layout of a work group or department. By drilling down on the "where" question, you may recognize subtle but potentially important causes such as: "in the corner where the lighting is poor." This knowledge prompts you to ask during the analysis phase, "why is the lighting inadequate?"

Problem definition is not only the first step toward problem solving; it is the most critical step. Lasting solutions cannot be devised until everyone involved clearly understands the problem from all perspectives.

Once the problem is defined clearly, it’s time to look for solutions. The best ones will prevent problem recurrence and meet your goals. To find the best solutions, it’s important that the root causes of the problem have been identified. Don’t guess at what may be causing the problem, or you may end up with ineffective solutions. For example, you are interested in reducing the number of elective surgeries that are cancelled after the patient has been admitted. The multidisciplinary team working on the project first identifies all possible causes of cancelled surgeries, as shown:

  • Patient condition destabilized.
  • Patient not properly prepared.
  • Preoperative tests not completed.
  • Relevant patient information not available immediately prior to surgery.
  • Surgeon or anesthetist unavailable.
  • Equipment not available.
  • Unexpected change in the OR schedule.

The team decides the data must be collected to ascertain which of those are most prevalent and whether there may be other causes that were not identified. Once the most common causes of cancelled surgeries are validated, focused solutions can be developed and implemented. If the data do not show what is the real cause or how different causes interact to produce the problem, it may be necessary to go back and reevaluate the situation. Don’t make the mistake of shortcutting the data collection phase and too quickly start working on a solution. This can result in solutions that have nothing to do with the real root cause of the problem. Making the judgment about when to move to the solution is difficult and one reason why effective problem solvers clearly separate the investigation step from the solution phase.

If the data show with enough certainty the real causes of the problem, it’s time to move on to planning how to resolve the problem. The data-gathering and analysis phase enables you to understand the causes of the problem, to model the problem system, and to think of possible solutions.

Solution development is a two-step process. First, in the creation stage, each cause is investigated and solutions are offered. Next, evaluate each proposed solution against the three solution criteria: prevents recurrence, is within our control, and meets our goals and objectives.

The solutions are more likely to be effective if they are supported by clear evidence-based cause-and-effect relationships and meet the three solution criteria. Be careful during the solution phase. A common tendency is to transfer responsibility for the solution to others. For example: "We would have fewer surgery cancellations if staff in the surgeons’ office would just remind patients to arrive at the hospital one hour prior to surgery." By doing this, we put the solution outside our control, and thus it violates one of the solution criteria.

To be effective problem solvers, case managers, as well as other people in the organization, must develop the ability to thoroughly understand the causes of problems. Case managers can begin to arrive at solutions that all stakeholders will support by systematically observing and documenting problem situations over time.