may discover that the new computerized documenta- tion system is not user-friendly. By distinguishing the problem from the symptoms of the problem, a more appropriate solution can be identified and implemented.
Develop Solutions
The goal of generating options is to identify as many choices as possible. Occasionally, rigid “black and white” thinking hampers the quality of outcomes. A nurse who is unhappy with his or her work situation
and can think of only two options—stay or quit—is displaying this type of thinking.
Being flexible, open-minded, and creative— attributes of a critical thinker—is critical to being able to consider a range of possible options. Everyone has preconceived notions and ideas when confronted with certain situations. Although putting these notions on hold and considering other ideas is benefi- cial, it is difficult to do. However, asking questions such as the following can allow a person to consider other viewpoints:
FIGURE 6-4 Analysis of root causes of referral problems. CCS, California Children Services.
Man power (people) Materials
Methods Machines (equipment)
Problem: New referrals are not completed within 45 days Vacant positions Continuously training new staff Staff not knowledgeable of CCS program
New CCS administrator has no experience in program
Workloads are uneven
Forms are poor quality and hard to read Some forms are not in Spanish
Not enough chart cabinets in case management rooms
Not enough fax machines Not enough laser printers Parents do not complete the CCS application
Staff meetings focus on blaming and complaining
Lack of institutional memory No formal training is offered
Patient names and addresses are often incorrect
Patient charts are in a different room
Referrals are incomplete
Desk is not covered during employee vacations Laser printers and fax machines are not
located where staff work
New referrals come in different ways
New referrals are not timely passed to team
• Am I jumping to conclusions?
• If I were (insert name of role model), how would I approach it?
• How are my beliefs and values affecting my decision?
Select a Solution
The decision maker should then objectively weigh each option according to its possible risks and conse- quences as well as positive outcomes that may be derived. Criteria for evaluation might include vari- ables such as cost-effectiveness, time, and legal or ethical considerations. The options should be ranked in the order in which they are likely to result in the desired goals or objectives. The solution selected should be the one that is most feasible and satisfactory and has the fewest undesirable consequences. Nurses must consider whether they are picking the solution because it is the best solution or because it is the most expedient. Being able to make cogent decisions based on thorough assessment of a situation is an important yardstick of a nurse’s effectiveness.
Implement the Solution
The implementation phase should include a contin- gency plan to deal with negative consequences if they arise. In essence, the decision maker should be pre- pared to institute “plan B” as necessary.
Evaluate the Result
Considerable time and energy are usually spent on identifying the problem or issue, generating possible solutions, selecting the best solution, and implement-
ing the solution. However, not enough time is typi- cally allocated for evaluation and follow-up. It is important to establish early in the process how evalu- ation and monitoring will take place, who will be responsible for it, when it will take place, and what the desired outcome is. Be prepared to make mistakes and take responsibility for them. The key is to learn from mistakes and use the experiences to help guide future actions, or, as Henry Ford said, “Failure is only the opportunity to begin again more intelligently.”
Individuals and groups may not adopt a structured problem-solving approach because it takes too much time, the process may be boring, people are too busy to get involved, and participants may perceive there is little or no recognition for their participation. Leaders should be cognizant of these potential barri- ers to prevent or minimize them.
Maxwell (1999) proposes a T-E-A-C-H method for approaching problem solving:
Time: Take the time to discover the real issue (e.g.,
root cause analysis).
Exposure: Learn what others have done.
Assistance: Have members of the team investigate
all aspects of the issue.
Creativity: Brainstorm to identify multiple possi-
ble solutions.
Hit it: Implement with best solution.
Regardless of the model or approach taken, using a systematic approach helps address issues in an orga- nized and focused manner. All nurses, whether they are managers, leaders, or followers, need adequate problem-solving and decision-making skills to be effective in their roles.
THE SOLUTION
In a previous job, I had used multidisciplinary process improvement teams (PITs), which consisted of key stakeholders, to initiate process improvement. I chose to try this concept in this setting. Our team consisted of the public health nurse (PHN) case managers, the CCS case workers, the billing and claims staff, the CCS medical director, clerical and support staff, and me. I believed that a group approach to these problems would yield the most information and gain the greatest support for any changes that would be made. The team met weekly for an hour. We began by identifying our custom-
ers and key stakeholders and their expectations. This was extensive and took a few months to complete. Key stakeholders included the patient (children) and their parents, the providers (physicians and hospitals), pharmacies, vendors, schools, other insurance plans, the taxpayers (state and county), our own team members, and other agencies. The expectations for each stakeholder were listed, dis- cussed for clarity, and recorded. During this exercise, the team learned a great deal about each person’s job duties (there were a few surprises) and about the effect each person’s job had on other