Finding the Problem: Avoiding the Misguided Search
One of the buzzwords in long-term care is looking for the "root-cause" for various problems that arise. Many of these "root-cause" searches are often based on resident care. Others are often facility-based, especially related to financial information, staffing, and general supplies and facility maintenance. However, many of these supposed "root-cause" analyses often fall far short of ever finding the supposed cause that they were set to initially determine. In fact, many frequently become side-tracked and move into other areas, compromising their focus on the initial target. What follows is a brief overview of a few major issues that lead to problems in long-term care never being discovered and subsequently addressed.
Failure to Understand and Find the True Problem
To be able to address a problem, the problem has to be clearly defined. It is common to find and address a problem. However, whether it is truly the problem that is leading to the issue is a totally different story. The successful amelioration of a problem is incumbent upon defining the appropriate problem. All too often attempting to isolate what the true problem is provides considerable difficulty. The reason for this is that often there are a number of potential issues that are closely related. Yet, each of these issues may have considerably different ramifications. However, without being able to isolate the specific issue or problem that leads to the particular health care consequence, the person is left chasing rainbows.
Finding the specific issue and then defining the problem is much more difficult that it appears. This author has provided simple, single paragraph problems to his classes in which they were instructed to find and isolate the problem that brought about a particular scenario. When the problem was imbedded with other superfluous information most individuals often failed to identify and isolate the specific problem or issue. Many targeted the consequence, and not the problem. Furthermore, many others often would isolate the superfluous issues that were not even close to being related to the true problem. Without any training, isolating a problem that is leading to the consequence of a particular situation is quite difficult. Yet, in health care situations, adjurations are often made for health care professionals to undertake this task as if it is easy or as if long-term care professionals and administrators are well-practiced and proficient at this task. Many of these individuals are often surprised to find out how a seemingly very simple problem in a single paragraph is unable to be clearly isolated and articulated. Therefore, given these results it should be no surprise to find that many individuals often fail to find and express the true problem in real-life situations when these problems are often much more intertwined with a myriad of other closely aligned, yet different problems, all leading to very different consequences.
The Illusion of Cause
Cause if often referred to as the goal in examining problems faced within any health care area, including long-term care. However, the image of a person often finding and isolating a single cause, as is often misleadingly made during such techniques commonly referred to as "root-cause" analysis, leads to an impression that there is often a single root cause that can be found for everything. This is a residual aspect of the Platonic vertical process of thinking, which asserts if you dig deep enough you will always find the quiddity for anything. However, this is far from being the reality that exists. A single "root-cause" is often not a reality, since often there is frequently more than one antecedent that can lead to a single cause. Furthermore, a single antecedent can lead to more than one consequence. Moreover, often the best that we can find is not a cause but a number of correlations, often failing to understand the distinction between causative and correlational findings. As one can see, something that is often conveyed as being a facile assignment of finding a problem is quite complex and needs considerable training. Far from what most higher level managers or executives assume when they mandate these problem-solving assignments onto their staff, this assignment, looking for a "root-cause" or any type of cause, is far from manageable for most individuals who fail to have proper training in this area, including most upper level managers.
Moreover, think of a simple cause that you do find. A simple cause (C) will often have many subcomponents involved (C1...........Ca). Take for instance something apparently simple such as turning on a light. What causes the light to be turned on (C)? The person flipping the electrical switch? However, is that the cause? Yes, but not the sole cause. What about the switch making proper contact? What about having a proper electrical conduit? What about the need from proper electrical wiring? What about paying the electrical bill to maintain electricity coming into the home so the switch can activate the process? Also, what if all of this is in place and there is no bulb within the light socket? As one can see, C (turning on the light switch to turn on the light) actually subsumes a number of other features that also are part of the causative process.
What about a person that has a medical issue such as an ischemic cardiac incident? Apparently, since it is an ischemic issue that should be the cause (C = ischemia). Although that may be viewed as the proximal cause, could there be others. Could volumetric changes in the blood and viscosity also be issues that are even more proximal? What about the inadequate nature of certain clotting factors? What about continuous lack of mobility leading to thrombotic features to form? Could a poor diet of fried food and saturated fats be causative? Could the lack of exercise have led to this issue? Could heavy smoking, along with a generally unhealthy and sedentary lifestyle have been the true ultimate or root cause? Here again, we see a number of causative factors that often are inclusive in what many individuals have assumed is the apparent cause. Is what was thought to be the apparent cause (ischemia) just the most recent and proximal of many other linkages that were more distally causative? Look at the complexity that just in these brief few paragraphs have been brought to the attention of the reader. And yet, when many long-term care personnel are instructed to find root causes, personnel who have often little if any training in this area, the assumption is that they will assuredly find the root cause. What is even more disconcerting is that those that do the investigation, frequently in a cursory manner, often come away with a false self-confidence in their results, thinking that without exception they have found the elusive, quintessential factor that led to the problem.
So What are the Consequences?
Problems are an endemic part of life. Finding the reason for their existence and attempting to solve these problems are an unending quandary that we face as part of life. Problems in long-term health care situations are no different? Whether it is attempting to find the reason behind unanticipated hospital admissions, or why average staffing ratios are running higher than in other facilities, or even why family members are selecting other facilities over your facility, many mistakes are often made toward attempting to find and solve important problems.
Thinking that one will always find the so-called "root-cause" is one major misattribution. Many problems quite simply will never manifest a clear "root." Furthermore, assuming that there is only a single cause is also quite problematic in itself. Even though many executives are adjuring their staff to "find the problem," they themselves, referring to the "problem" in its singular form are framing the issue in such a manner that those that will approach the problem will think that there is a single cause. Even the concept of "root-cause analysis" often conveys that a singular cause can be found and is always there to be apprehended.
Furthermore, another issue that has been mentioned is that individuals will often approach problems in health care without a clear understanding of what the problem is. Failing to clearly isolate and identify the problem will provide a totally misguided approach to solving any particular problem. Regardless of the assiduous nature of your investigatory endeavor, you could painstakingly follow a wonderfully deductive and logical approach that achieves a perfectively sensible result and solution. Yet, if you start off with the wrong problem, the solution will nevertheless be incorrect. For instance, consider the following:
- All dogs have three legs,
- Buck is a dog,
- Therefore, Buck has three legs
Is the syllogism above logically correct? Yes, but is it true since it started out with an incorrect major premise (All dogs have three legs)? No, it is absolutely not true. Even though it is deductively valid, following the steps to achieve a logical conclusion, starting out with an incorrect premise still leaves us with a valid conclusion but one that is not true-all dogs do not have three legs. The same exists for those that start off by defining the problem correctly. A valid conclusion may be deductively found, but it may have nothing to do with the correct problem.
Thinking that solving problems correctly in long-term care can be achieved by anyone and just by using a little hard work is a very misguided assumption. Problem solving is something that needs considerable practice and training. All too often, problem solving, not just in long-term care but in all health care is approached with an ill-conceived, loosely structured, and even a somewhat cavalier attitude. However, hopefully after reading this paper, individuals will see that problems, finding them and solving them are often far more complicated than many think and that it often entails a considerable level of training and practice to become proficient at such a practice. Understanding the complexity of problem solving and consistently practicing your skills and avoiding some of the common errors that have been discussed will ultimately lead to addressing many concerns that arise within long-term care in a more insight and productive manner.