Handling an unsolvable problem.

In an effort to increase revenue and meet the needs of a growing population in its community, a hospital decides to increase its emergency department's volume capability. The facility is updated and expanded. Increased marketing efforts to both the public and referring physicians lead to rapid growth.

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The hospital administration and board of directors are delighted. The physicians and nursing staff, however, are overwhelmed. They complain to anyone who will listen, that quality of care is suffering at the expense of increased volume and money for the hospital.

The hospital counters by stating it gave the clinical staff everything it asked for in terms of increased space, new equipment, and better technology. Quality will not suffer if the clinical staff just learns to work smarter and more efficiently.

The debate continues and no one is happy. An angry CEO gives the vice president of medical affairs the job of solving this problem. Where does the VPMA begin?

Solving the unsolvable

As the VPMA approaches this assignment, the first question he or she must ask is not, "How should I try to solve this problem?" but rather, "Is this a problem which can be solved?"

Barry Johnson in his book, Polarity Management: Identifying and Managing Unsolvable Problems (1) identifies four questions to ask to determine whether a problem is solvable or not.

Is the problem ongoing?

In our case above, the answer is an obvious, yes. The clinical staff continue to believe that quality suffers with the increased volume, while the hospital administration believes volume must increase to generate revenue to stay in business. There is no definitive endpoint to these arguments.

Are these two points of view interdependent?

Again, the answer is yes. You do not want either quality or revenue. You want and need both to be successful, making them interdependent.

Next, are there upsides to both points of view?

Both points of view have obvious upsides. Increased quality improves patient care and outcomes. Increased revenue funds new programs and additional resources.

Finally, will focusing on the upside of one point of view to the neglect of the other undermine the organization's efforts to be successful?

Focusing only on improving quality may undermine efforts to meet the medical needs of the growing population in the community. Likewise, focusing only on increasing revenue may result in staff burnout and loss of experienced personnel.

Based on our answers to these questions, it becomes obvious there is no "right" answer to this problem. Johnson argues that rather than trying to find a solution to an unsolvable problem, we must develop a strategy to manage the dilemma we are faced with of increasing revenue and maintaining quality.

Determining the dilemma

How then does the VPMA approach managing this dilemma?

First, key stakeholders of both points of view must be identified and brought together. Both points of view must be acknowledged and supported as being true. The accuracy of both points of view is not challenged. No side should be asked to contradict or deny their point of view.

Instead, the point is to get each side to supplement their point of view with a second point of view, which also is true. In doing so, they will be helped to recognize this is not an "either/or" problem to solve, but a "both/and" dilemma to manage.

Having accomplished this, they must move to identify the key dilemma facing the group. In this case it is easy, since we already have identified maintaining quality and increasing revenue as the dilemma to manage.

The next step is to create a visual representation of the dilemma. This is accomplished by creating a four-quadrant matrix as defined by Johnson. (1) As can be seen in Figure 1, the upper left quadrant represents positive results from focusing on only quality issues.

The lower left quadrant represents negative results from focusing on only quality issues. Likewise the upper right and lower right quadrants represent the positive and negative results of focusing on revenue.

The goal of the stakeholders is to define both positive and negative outcomes in each of the four quadrants. For organizations that attempt to solve these dilemmas as problems (ignoring one side of the matrix at the expense of the other), the tendency is to move from the positive quadrant of one pole to the negative quadrant of that same pole (positive outcomes of quality to negative outcomes of quality).

To solve that issue, the organization directs its efforts to attain the upper quadrant of the opposite pole (revenue), at the expense of the opposite pole (quality). Eventually, it will experience the downside of focusing only on revenue, leading it to focus on quality again. The result is an endless flow loop.

With the dilemma and positive and negative outcomes mapped into the four quadrants, the group must develop a plan to either place or maintain the organization on the upside of the matrix, achieving positive outcomes of both quality and revenue.

For this example, it might require determining the optimum capacity of emergency department admissions, which will maintain quality but still allow volumes higher than previously attained before the renovations.

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The message to the staff, community, and referring physicians is that all effort will be made to accommodate as many patients as can be cared for without jeopardizing quality or safety.

Finally, since by definition there is no endpoint in a dilemma, the group must anticipate and identify issues to prevent movement to the downside quadrants of the matrix. These might include events such as a drop in referring physician satisfaction scores in relation to the emergency department or increased turnover among the emergency department staff.

Having identified these potential problems, processes must be developed to collect and analyze the data, notify the appropriate hospital and clinical leaders who have the authority to take action and define action plans ready to be implemented should these events occur.

As first- and second-year medical students, we are taught to look for "the solution" to a clinical problem. What we discover as we progress through our training and career is that often there is not one "right" answer. Instead, we come to realize that most patients' clinical problems are the result of the interdependence of disease states with culture, social issues and behavior.

Likewise, as physician executives we must realize that management problems may not have one solution. As with our patients, there may be many interdependent "right" answers. By learning to recognize and manage dilemmas, physician executives can gain a powerful tool to address unsolvable problems.

David P. Tarantino, MD, MBA, is executive medical director of Shock Trauma Associates, P.A., a 50+ physician, multispecialty practice associated with the University of Maryland School of Medicine. In addition, he is the chief executive officer of The MD Consulting Group, LLC, a health care management consulting firm in Baltimore. He can be reached by phone at 410-328-2036 or by e-mail at [e-mail]

Reference

1. Johnson, B. Polarity Management': Identifying and Managing Unsolvable Problems. Philadelphia, HRD Press, 1996

By David Tarantino, MD, MBA

Quality                         Revenue

Positive Results                Positive Results
* Better Outcomes               * Fund New Programs
* Increased Referrals           * Update Technology & Equipment
* Gain in $ for "pay for        * Increase Personnel and Resources

Negative Results                Negative Results
* Unable to Meet                * Loss of Staff
  Patient/Community Needs       * Loss of Patients due to Decreased
* Loss of Referrals Not Enough    Satisfaction
  Volume to Maintain Adequate   * Increased Legal Action
  Revenue