Byline: Vincent D. Robbins, FACHE
Problem-Solving for Pros
Much has been written about how managers can make decisions and solve problems. In fact, management theory has developed many models over the years to explain how problem-solving decisions should be made. These models and their processes can differ from one industry to the next and can become quite specific in certain fields. This article looks at the types of problems we encounter in EMS and mobile healthcare and techniques that work well for our industry.
Problem-solving skills taught to managers of EMS and mobile healthcare agencies are usually relatively straightforward, linear processes. It is rare that our managers are educated in the area of solving difficult problems and learning about problem classification or multiple approaches. More commonly they learn and use single methodologies and incorporate a single approach into their management style. While this may serve them well for a majority of the daily, routine problems they encounter, it will fail them miserably when they are challenged with the worst, most intricate problems.
When catastrophic issues, unanticipated complex problems or problems that evolve into cascades occur, the manager who can't rapidly and competently shift to alternative resolution techniques will flounder. These problems will quickly overwhelm such managers, threatening collapse of their systems. Problems such as these can burst upon the scene with little to no warning, or they can grow insidiously over time. Regardless, they require the manager to recognize their type and employ the correct problem-solving process to thwart them.
The Decision-Making Process
Decisions are almost always an attempt to resolve a problem. The type of problem can dictate the method of decision making needed. The general process is classically linear in progression and divided into the following steps (not necessarily in this order):
1. Clearly identifying what the decision is intended to achieve. This includes precisely determining what the problem is.
2. Gathering all the information available, including the problem's nature, origin, precipitating factors, exacerbating and mitigating influences, history and recurrence. This step is where root cause analysis is done.
3. Engaging others, either groups and/or experts, to assist in the process if needed.
4. Identifying all actions that would resolve the problem.
5. Analyzing the anticipated effect of each action, including:
* Its adequacy in solving the problem;
* Identifying collateral consequences that will result other than solving the problem;
* Assessing the balanced success of each action, i.e., weighing the importance of the positive result (solving the problem) against negative results from other consequences of each action. The Pugh Matrix (see sidebar) is helpful in the comparative process.
6. Selecting the overall best action toward solving the problem.
7. Taking the selected action.
This a traditional overview of the decision-making process. However, important and specific variations should be made based on the type of problem encountered. More critically, the actual sequence of steps should change depending on the problem's complexity.
Based on the Cynefin framework (see sidebar), problems tend to fall into several domains, from relatively simple, single-faceted issues to complex problems with multiple elements. At its core, the framework categorizes problems into the following types:
Simple--A simple problem is one where the cause-and-effect relationship is clear and obvious. Analysis is really unnecessary. Often organizations already have predetermined solutions for this type of problem. These are the kinds of problems addressed by policy and procedure manuals and operations protocols.
Complicated--This type of problem requires an analysis or expert review before the relationship between cause and effect can be determined. Root cause analysis is effective with these kinds of problems.
Complex--With these types of problems, cause and effect can only be determined after the fact, not in advance. Attempts to analyze in advance of action are relatively useless.
Chaotic--In this domain, the cause-and-effect relationship does not exist at a systems level at all.
Disorder--The type of causality of disordered problems is not knowable. As other types of problems go unaddressed, over time they can transition into disorder as they cascade and domino, causing more problems of increasing intricacy. Cause and effect become compounded and multifaceted.
There is another, special set of problems classified as wicked. Wicked problems are difficult to impossible to solve because of incomplete or contradictory information and constantly changing requirements for resolution. These kinds of problems are primarily those requiring changes in the behavior of large numbers of people. They also exhibit the following characteristics:
* Disagreement exists on exactly what the problem is.
* Taking action(s) to solve wicked problems results in additional problems.
* Each one is essentially unique.
* They are symptom of other problems.
* There is no immediate or ultimate test of any solution. This makes it difficult to assess whether an imposed solution is working.
* They have more than one solution.
* Their solutions are not "right" or "wrong," but rather good or bad.
One would tend to classify simple, complicated, complex and chaotic problems as tame, while those that transition between them or reside in the disorder domain would more likely be wicked.
To select the best process for resolving a problem, managers must determine what kind of problem they're dealing with. Once that's identified, the most effective approach to resolving it is straightforward.
Approaches to Resolution
Modern management theory describes approaches to solving the different types of problems:
For these problems we follow existing best practices, already established. The manager realizes there is a problem, identifies it as within a known category of similar or like problems, and proceeds with a predetermined solution, following policy or protocol.
These problems are addressed by analyzing them, with the root-cause analysis approach if needed, determining the cause-and-effect relationship and then what actions are necessary. With these problems, we don't have existing answers to use but must create new ones. With no best practice to pursue, we create our own new good practice.
With problems of this nature, with no cause-and-effect relationship discernable in advance, the approach is to first probe, or take some limited actions to elicit more information regarding cause; then analyze (sense) the result or consequences of action; and finally respond (render the solution). The response in this case is considered emergent practice.
When the problem is such that there is no relationship between cause and effect, the manager must impose a solution (act) based intuition, essentially what he believes is the best way to address it given his experience and judgment. Then he analyzes what occurs as a result of his solution and modifies the solution to resolve unintended or negative consequences (responding). In this case the manager has invented novel practice.
These problems require one of several approaches to solve.
First, if possible, a wicked problem should be broken down into constituent problems that fall into the other four Cynefin domains and then addressed accordingly. However, this is not always possible. Many times wicked problems are not conglomerations of many other tame problems but single issues in and of themselves.
Otherwise, wicked problems can be handled in one of three ways. There is not necessarily one preferred method, but sometimes the best approach is evident given the circumstances.
Authoritative approach--This strategy vests responsibility and decision making into the hands of a few people who are empowered to act unilaterally to address the problem. This method affords a more rapid response but lacks the cooperative characteristic for stakeholders that is sometimes needed.
Competitive approach--With this method, stakeholders are divided into a small number of groups with like mind-sets or special interests. These groups are each charged with addressing the problem. Their solutions are weighed against each other in an attempt to determine the best overall response. The Pugh Matrix (Table 1) can once again be helpful here.
Collaborative approach--Under the collaborative method, stakeholders are engaged directly through joint meetings (or other venues aimed at ensuring participation) and asked to work as a single group in solving the problem. Often this process must be facilitated by an impartial person or entity to ensure all points of view are assessed. The groups come to a consensus on the best course of action.
As we know, some problems are relatively easy to solve, while others can be extremely difficult or even impossible. Regardless, in order to be successful, managers of EMS and mobile healthcare systems must be flexible and capable of changing their problem-solving techniques.
1. Churchman CW. Guest editorial: Wicked problems. Management Sci, 1967; 14(4): 141-2.
Since 1990, Vincent D. Robbins, FACHE, has served as MONOC's president and chief executive officer, responsible for the oversight, administration and management of three healthcare services companies. Formerly he served in the administration of Temple University Hospital in Philadelphia and with the New Jersey Department of Health's Office of Emergency Medical Services.
The Pugh Matrix
Named after Stuart Pugh of the University of Strathclyde in Glasgow, this method uses a matrix with an x and y axis to score different solutions to a problem based on established criteria. It is often used with a team approach to resolution.
Table 1: The Pugh Matrix
Criteria Baseline Weight A B C D
1 0 2 +1 -1 0 +1
2 0 4 0 -1 0 +1
3 0 3 +1 +1 +1 0
4 0 5 -1 0 0 +1
The Cynefin Framework
The Cynefin (pronounced kuh-NEH-vin) framework was developed by Welsh knowledge-management expert David Snowden to describe the different processes needed to resolve problems based on their level of intricacy and uncertainty. It categorizes problems into domains and then assigns sequential steps to determine resolutions.
Table 2: The Cynefin Framework
Problem type Steps needed Result
Simple Sense, Categorize, Respond Best practice (established)
Complicated Sense, Analyze, Respond Good practice
Complex Probe, Sense, Respond Emergent practice
Chaotic Act, Sense, Respond Novel practice
* EMS/mobile healthcare managers are rarely taught problem classification or multiple approaches to solving complex problems.
* Different problem types require different steps to resolve.
* Successful managers must be flexible and capable of changing their problem-solving techniques.
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