Wicked Problems Need Collaborative Solutions

A standard gambit in candidate interviews is, "Tell me about a problem that you have solved". Reasonable professional expectation? Nope. Depends on what kind of problem the interviewer is expecting to hear about. Different problems; different problem solving. Only one of four types would be reasonable for an individual to solve.

The last two blog posts outlined three problem types each of which requires a fundamentally different response for solution. One way to sort problems is in a 2x2 grid: degree of knowledge we have about the problem and the degree of consensus on the appropriate response. Please see http://www.currycorp.net/blog.html?id=182 on Simple and Chaotic Problems (Quadrants 4 and 1) and http://www.currycorp.net/blog.html?id=183 on Crazy Mad Problems (Quadrant 2).

Wicked Problems are the remaining problem type, Quadrant 3. These are understood well enough, but there is no agreement on effective response. Often the range of responses offered are piece-meal, contradictory and viewed with suspicion by other parties. Thus, there is no effective response. Sometimes this means that we willfully ignore or minimize the whole problem (e.g. educational disparities); sometimes we tolerate uncoordinated responses across involved parties (e.g. healthcare); sometimes we console ourselves that it is not our problem to solve (e.g. homelessness). All at great cost to society.

The problems of high risk, high need patients with multi-morbidities belong in this quadrant. Here there are multiple simultaneous problems, each of which is well understood and has an agreed solution, but in interaction the solutions are conflicting. These patients are big resource users in health care systems and are increasing in numbers. Still, there is little or no coordination in their preventative, acute or chronic care. There is no expectation for smooth and timely flow of information or instructions across the many sectors, sites, specialists, programs, providers and supporters involved. Everyone works in his/ her silo. Unknown treatment interactions occur; possible synergies are not sought; expensive duplication is rampant. Worst of all, there is no center of responsibility for resolving these clashing solutions so patients and their families are left to make whatever sense they can of the situation.

Another kind of quadrant 3 problem occurs when there is an unacknowledged clash of values and world views each of which produces a prescriptive approach to the problem. An example is the widespread systems phenomenon of misaligned resources across sites of need and opportunities for intervention. Most tertiary care hospitals are in cities and are operating at or above bed-capacity for extended periods while surrounding, smaller community hospitals are near empty. Operating rooms in city hospitals are overbooked and cancelling surgeries while ORs in community hospitals are closing or losing key staff. This is not a problem if the value basis is that all the hospitals are in competition: market forces will make big hospitals bigger and the community hospitals will disappear. It is a problem, however, for any definition of the wider public access to timely, cost efficient care. Here our knowledge of how to appropriately meld managerial and care provision values is insufficient but we proceed with the status quo anyway, wasting resources and harming patients.

Another area lacking response consensus is how to create and sustain effectively collaborative care communities. Faced with a shared problem, each professional community frames and solves their perception of the problem in their own way; sometimes overlapping; sometimes duplicating; always in a vacuum of not knowing or trusting the other communities of care. A common example of this type occurs in the provision of preventative primary care to seniors. One third of emergency room visits by seniors could be avoided with better integrated care provided upstream, at home or in long term care residences. This doesn't happen for several reasons, primary among them is the lack of social consensus on how to appropriately decentralize care and require the various care communities to cooperatively organize their work around their shared client.

What kind of problems are you and your organization facing? Which have you acknowledged, which are you ignoring, which are you tolerating? When you ask your staff and applicants about problem solving, which type of problem are you asking about and what type of response are you looking for?

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