Don't fix it. (Next!).

What's the problem with fixing a problem? You identify a problem, you fix it. No problem, right?

Not really. Next to doing nothing, fixing a problem is often the worst thing you could do with it.

Executives in one major health care center we know of fixed a problem recently. The ICU needed more computer power. So the IT guys put in a new computer, new input devices, the whole schmear. Problem fixed? No. Instead, the result was: Interminable interdepartmental strife, meetings, accusations, lots of antacids consumed, and finally the new computer system ripped out and replaced with another new computer system. Cost: In the millions.

Why? Context. Fix a problem, miss the context, now you still have the problem--only it's bigger, it's weirder, it costs more, and everybody's grumpy.

Context

This universe is organic, not geometrical. Weirdness happens, connections are not always obvious. Look for a new antibiotic and find a cure for malaria, a parasitic disease. Set out to inoculate all the kids in the county and end up with a new adult literacy program.

In a sector as complex as health care, there are few absolutes and few isolates. There is always "the rest of the story." There are always side effects, unintended consequences, "unk-unks"--unknown unknowns.

The unk-unks of context are not problems, they are opportunities. When something comes at you with a "problem" label, use it as an opportunity to connect things up. Explore the context.

Start with the context of the problem itself: Who owns the problem? Who else is affected by it? Who is involved in the solution? Who should be? Who's going to use the solution? How can you engage them? How does the problem change its shape when looked at from a different perspective?

In the case we mentioned, the IT people owned the problem, not the ICU nurses. From their point of view, the problem was bringing the new ICU computer in on time and on budget. In their zeal to fix the problem, they neglected to ask the nurses what they needed, where, what kind of input device, what sorts of information they wanted. When they were done, the system was installed, and now it became the nurses' problem. From their perspective, the problem was running the ICU with this new computer-a problem that proved so intractable that eventually the IT people had to start over from the beginning.

After the context of the problem itself, explore beyond it: How did the problem arise? What are you really trying to solve here? Is there a perspective from which the problem turns into an opportunity, in which, say, the problem of patients getting lost coming in from the parking lot becomes the opportunity to have volunteer greeters give patients a more human welcome to the institution.

Finally, look at the big picture, the reasons we are all involved in health care: What is the opportunity here? What kind of relationships and alliances can we create or strengthen? How could a change here help everyone concerned-patients, clinicians, family, other employees, the community?

You're fired

It happens on a personal level, as well. A client recently had a basic career problem He lost his job. Solution: Get another one. Outcome: Wasn't looking good. He found that his job search had little enthusiasm in it until he shifted the question to: What is the opportunity in losing a job?

He found that he had left out several big chunks of context. One was the industry: He had lost his job not through personal failings or office politics, but because his part of the industry was shifting its focus. There was no longer as much need for the particular work he had been doing.

Another piece of context was his life: He had, in fact, many other talents that were going unused. He had a wealth of contacts--and he had a deep desire to be more in command of his time, to create a more satisfying and balanced life.

When he was able to step back and look at these contexts, the decision was clear: He would not get a job after all. Instead, he would create a freelance practice using more of his skills and contacts. Within a year he was making several times what he had previously made, and his life was far more in balance.

Choice

Usually, when we confront a problem, we react: There's a fire, so reach for the fire extinguisher.

When we react, we often don't question the relative importance of things. ("Is it all that important that we get the budget done by Friday? We still have a week before the presentation.")

And just as often, when we react, we don't notice what we are stepping over to get to a solution. At one client, the board spent much of a meeting worrying about the proper business alignment with the doctors, and only mentioned in passing their severe labor problems with their nurses, with the resulting understaffing, morale, and training issues. In focusing on the one problem, the board was missing the larger array of choices that would come of asking: "Is this an isolated problem? Or is there something systemic about it?"

The opposite of reaction is choice. Here's one way to spot the difference: When we choose, we have a range of possibilities. We can choose between those possibilities, or create new ones. We can set a course, get feedback about what does and does not work, and make course corrections.

When we react, on the other hand, it feels like we have only two choices: "Either I cave into this knuckle-dragger, or I cause a huge stink," "If I don't put the staff on overtime to get the budget done by Friday, I'll have to do it all myself." Either this works, or it doesn't. I fix this or I fail. When you have two choices, you don't really have a choice. You have a dilemma.

Real choice is about creating opportunities. To get from dilemma to choice, back up until you find a perspective that offers other possibilities.

The illusion of choice

Sometimes an illusion of choice covers a reactive dilemma. In another recent meeting, a health care executive totted up a half dozen different strategies for "getting the docs on board." The strategies seemed to offer lots of options, but underneath lay a single dilemma: The docs were either (a) on board or (b) not.

Getting to choice would mean backing up and asking, "How did we get into the position of trying to drag the docs on board? Why is this a problem of 'How do we align the docs?' How did the situation get defined so narrowly? Where would we naturally align without all this huffing and puffing?"

A dictate from management is not an opportunity for those receiving the dictate. It's not a choice, it's a problem. It seems to offer an array of possible responses, such as "support enthusiastically," "support grudgingly while dragging feet," "actively sabotage," "protest loudly through proper channels," "form a union (or get the union involved)," or "quit." Under all these choices lies a dilemma: Do I accept this dictate from above, or not?

Because a management dictate creates a dilemma, it is not possible for employees to freely choose to follow it. They were not involved in creating the knowledge on which the decision was based, so for them it is not knowledge, it's noise. It's a problem.

People only have real choice when they participate in creating the possibilities. If a manager wants people to pour their hearts into what they are doing, the questions become: What am I doing that inhibits participation? What invites real participation? Where is the opportunity to engage people at their fullest?

Management dictates will get compliance-usually--but only compliance, the mere following of directions. Real participation is the only way you can bring people's intelligence and life experiences to bear on the situation at hand.

"Fixing" a problem often creates new problems, and often the fix even fails to correct the original problem, because it leaves out the context.

The "A list"

Here in Marin County, we had coffee the other morning with the head of the county's Health and Human Services Division, Nancy Rubin. She has an "A list" for herself and her department, and a "B list." The "A list" must be done. These items represent success or failure. The "B list" can be distractions.

But at first glance we were a bit mystified. The "B list" included items like "Trauma," "Affordable Housing and the Homeless," "Mental Health Access," and "Breast Cancer." They sounded pretty important. "And they are," she said. "They're extremely important. That's why they can be distractions."

The "A list" had only six items. They were:

* Shared vision, shared goals

* Health and Human Services as a community asset

* Information, data collection, and planning

* Collaborative management

* Labor relations

* Mann as a model

The "B list" is a list of identified problems. The "A list" is all about context and connection, within the department and between the department and the community. It creates the possibility of real change. If we neglect our "A list," nothing on the "B list" gets anywhere. Here we find opportunities when we blend "B list" tasks into the bigger "A list" of connection and context.

Conclusion

Fixing what's wrong doesn't fix what's wrong. Holding the conversation at a level that gives us real choices and creates new possibilities--these are the elements that move us toward true change.

Joe Flower is an internationally recognized health care futurist. Patrice Guillaume is a personal and executive coach. Their company, What If ... is dedicated to bridging the gap between what is and what's possible. What If ... offers a technology of inquiry that helps people and organizations imagine and build toward their own best future. You may contact the authors by calling 415/924-5036 or via email at [e-mail]