Identify and Quantify the Problem:

In simple terms a “problem” can be regarded as a difference between the actual situation and the desired situation. This means that in order to identify a problem an individual or group must know where it is meant to be (desired state) and have a clear understanding of where it currently is in relation to the perceived problem (current state). Problems are often confused with gaps. The gaps directly or indirectly cause the problem/issue. A problem alone without “definition” and specificity is less likely to lead to a solution.

When a decision-maker has a problem such as increased mortality in an  ICU,  (s)he needs to understand the gap(s) at the root of the problem. In the example below the clear gap was discovered to be high infection rates. More analysis made it apparent that the infection rate spike was due to multiple factors.

In analyzing this problem,  it starts to become apparent not only what the problem is but also what needs to be corrected to address the problem. We also glean from this example the metrics and outcomes that will need to be measured to demonstrate a successful solution to the problem. Beyond improved mortality rates, metrics such as sterile technique (bundle) compliance are key performance indicators, and adherence to established protocols is likely to  improve and hasten the diagnosis of infection of sepsis.

The difference in addressing increased mortality versus simply approaching a decision-maker wanting to improve communication should be clear. If the gap does not relate to a meaningful problem, then it is less likely to be prioritized by a decision maker. It is incumbent on you to make that case in a clear, concise manner. Often you have 5-7 minutes to pitch the need, so you need to articulate the bottom line up front.

For organizational leadership, a key consideration is the degree to which the problem negatively affects the organization financially and the alignment with the organization’s strategic plan.   Healthcare organizations face a multitude of competing demands.  Allocation of resources is typically based on the organization’s strategic plan (priorities) and the magnitude of the direct and indirect financial impacts on the healthcare organization.  Problems and proposed interventions should be presented in such a way as to align with organizational priorities and as solutions to the organizational leadership’s most pressing problems.

We are providing two cases to illustrate this stepwise approach: one central lines (CLABSI) infection rates and one on Helping Babies Breath Program.  In the example of central line infections, this may be an organizational priority based on a commitment to reduce hospital-acquired complications.  There are potential financial implications related to non-reimbursement of preventable complications as well as longer bed cycle times that reduce the availability of beds to care for other patients.

In the case of central line infections, there is good evidence that simulation training is effective in reducing central line infections, (Barsuk et al; Arch Intern Med. 2009;169(15):1420-1423 ) In addition the economic analysis of the effect of this training demonstrates a net cost savings as well as associated decrease in Length of Stay. (Cohen et al, Sim in Healthcare 2010)  This type of evidence is invaluable in engaging and persuading decision makers to invest in a particular solution.

With respect to the Helping Babies Breathe project, the considerations and stakeholders are very different. The United Nations identified as one of the millennium development goals the reduction of maternal, neonatal and childhood mortality (<5 yr) by two thirds, National governments and health ministries in resource limited settings identified high neonatal mortality rates as a priority for intervention.  Given the proposed resource limited settings, the simulators and educational material needed to function in the absence of electricity and computers. The educational materials needed to be usable independent of language and literacy skills.

When ready move on to Identify Decision Maker.