Asking The Right Question BEFORE Proposing a Solution

I was recently in a meeting where a solution was being proposed. The solution was interesting, but it was unclear what problem they were trying to solve. I asked if they could state the problem so we could make sure that the proposed solution had potential to achieve the right outcome. I was shocked that the person was unable to state the problem. How can you propose a solution if you don’t know what you are solving? It is like ignoring the problems on the math test and just writing numbers as a solution hoping that they work out. They had skipped the most important step in changing systems; they skipped problem formation.?

What is problem formation? This is the work to get to the real problem underlying all the detritus of life. What is the hidden problem behind the surface problem? Your partner is grumpy and, since we are all so egocentric, you assume that you did something wrong. You try to be nicer, and your partner only gets more upset. Why? You assumed that you did something wrong, but since you didn’t do anything wrong you can’t solve the problem by saying sorry. You need problem formation: instead of assuming the solution, start by asking the question, “Are you upset about something?” We are quick to assume and fail to see the problem behind the problem. That hidden problem is what really needs to get addressed to make meaningful change (see Evaluating Healthcare Systems through the "3 Lenses" for important insights on finding that hidden problem).?

My favorite example is the Washington Monument. The government was paying lots of money to have the monument cleaned. Someone asked why. Well, there is a lot of bird poop that must be cleaned. Why? The birds and bats are eating insects. Well, they do that everywhere, so why is the Washington Monument a target? Well, there are flood flights that illuminate the monument and bugs like lights and birds and bats like bugs and the monument was collateral damage. So, instead of spending money to clean the monument, they could turn the lights off. The lights are the real problem. The insects and the birds are secondary causes. True problem formation is to isolate the primary or root cause. But this kind of problem formation takes time and effort and a willingness to go ‘out in the field’ and talk with staff and customers to figure out what is going on. Because all humans like to take short cuts, often a solution is proposed to fix a surface problem that is easily identifiable. When the solution is applied to that surface problem, it doesn’t work fully because it wasn’t the underlying problem driving things.??

What is the problem behind the problem? Too often we take at face value that the problem we are facing is simplistic and obvious. Working with people who use drugs taught me vividly that there is often a hidden problem behind the surface problem. For many of the people with addiction that I cared for over the years, there was a history of violence buried deep that kept prompting the ongoing use. Simply taking a drug away from someone didn’t treat the real issue of trauma. Similarly, healthcare systems often have complex problems and if a hospital has an easy solution to improving something, stands to reason that they have simplified the problem and missed the mark. Getting actual data is critical to illuminate the problem. For example, I worked at a hospital where hematology complained they were getting referrals of poor quality from primary care. The assumption was that the providers did not know what they were doing, and education was the solution to that problem. I asked for the referral data and started going through it. It is true that a significant proportion of the referrals seemed unnecessary. The patients were rightly diagnosed with iron deficiency anemia and yet they were referred to hematology. Why? More digging showed that the primary care providers were not allowed to do iron infusions at this institution. So, the only way for a patient to gain access to an iron infusion was to be referred to hematology. In short, the problem was the system. The patient was already diagnosed and was waiting for a hematology appointment to verify that diagnosis so that the patient could obtain iron. Education was not the solution; rather a new process had to be developed. The problem was the process that required primary care to funnel patients to hematology. The solution was for primary care to be able to send patients directly to obtain iron infusions. Without an examination into the root cause driving dysfunction (see here for more on asking the right questions to get to that root cause), the proposed solution is often solving the wrong problem. ?

A failure to look at the data and critically investigate the root cause of a problem means that all the proposed solutions will be focused on a surface problem. Treating someone’s fever when they have pneumonia will bring relief and the person may feel better, but acetaminophen and ibuprofen do not treat pneumonia. They just treat a symptom. Too often solutions proposed in large, complex systems are treating the symptoms. And so, when the consultants leave or staff move on, that same problem resurfaces, and people wonder why. They should have expected that some manifestation of the root problem would return since it was ultimately never addressed. Often those simple solutions to surface problems wind up creating more problems. After all, you can die of pneumonia even though your fever was treated successfully with acetaminophen.?

Anyone who approaches you with a simple statement of the problem is either a genius or has skipped over much of the real issue. Usually it is the latter. Problems are complicated and if we do not get to the root, the weed will grow back.?So, spend time asking questions to get to the root cause and once you have that root cause visit Improving System Design in Healthcare for steps on how to fix that problem and transform your healthcare system.