1. Dr Lee Gruner- Discovering The Carrot Effect 1 The Art of Successful Problem solving Discovering the Carrot Effect

2. 2 Dr Lee Gruner- Discovering The Carrot Effect Format of workshop Introduction to problem solving Introduction to problem solving Barriers to problem solving Barriers to problem solving Understanding complex problems Understanding complex problems Real life examples in health Real life examples in health Reviewing the principles of solving problems successfully Reviewing the principles of solving problems successfully

3. 3 Dr Lee Gruner- Discovering The Carrot Effect Why did I write a book about how to solve complex problems?

4. 4 Dr Lee Gruner- Discovering The Carrot Effect Why did I choose to use rabbits as characters rather than people?

5. 5 Dr Lee Gruner- Discovering The Carrot Effect The tale of a difficult rabbit Once upon a time, there was a rabbit called Rominy Once upon a time, there was a rabbit called Rominy

6. 6 Dr Lee Gruner- Discovering The Carrot Effect Why was Rominy considered difficult? He was always right He was always right He always had a problem for others to fix He always had a problem for others to fix He always had the solution He always had the solution He never saw anyone else’s point of view He never saw anyone else’s point of view He had no perspective He had no perspective

7. 7 Dr Lee Gruner- Discovering The Carrot Effect The head of the rabbit clan was Walter Rabbit Walter had major concerns Walter had major concerns Rominy always wanted something fixed Rominy always wanted something fixed Rominy’s problems were really Rominy’s solutions Rominy’s problems were really Rominy’s solutions Rominy was very persistent Rominy was very persistent Rominy often got his way Rominy often got his way This was causing disharmony in the rabbit community as they thought this was unfair This was causing disharmony in the rabbit community as they thought this was unfair

8. 8 Dr Lee Gruner- Discovering The Carrot Effect Walter was a wise and consultative leader Walter held regular Walter held regular sessions on the Old Tree Stump to assist rabbits to solve complex problems

9. 9 Dr Lee Gruner- Discovering The Carrot Effect Walter was a wise and consultative leader But he had no idea of how he could solve the problem presented by Rominy But he had no idea of how he could solve the problem presented by Rominy

10. 10 Dr Lee Gruner- Discovering The Carrot Effect Walter believed in data To find out why Rominy had no perspective he decided to collect data To find out why Rominy had no perspective he decided to collect data The one thing that distinguished Rominy from other rabbits was that he was allergic to carrots The one thing that distinguished Rominy from other rabbits was that he was allergic to carrots So Walter collected data to see if this was the issue So Walter collected data to see if this was the issue

11. 11 Dr Lee Gruner- Discovering The Carrot Effect What did Walter find? Carrots v visual acuity Carrots v visual acuity No of carrots Rominy Rabbit 5 carrots

12. 12 Dr Lee Gruner- Discovering The Carrot Effect What did Walter find? Visual acuity and perception were directly related Visual acuity and perception were directly related Visual acuity was directly related to number of carrots Visual acuity was directly related to number of carrots Those who ate less carrots had less perceptive qualities Those who ate less carrots had less perceptive qualities Rominy was at the bottom of the scale for visual acuity and perception as he ate no carrots Rominy was at the bottom of the scale for visual acuity and perception as he ate no carrots The problem could not be fixed by feeding Rominy carrots The problem could not be fixed by feeding Rominy carrots

13. 13 Dr Lee Gruner- Discovering The Carrot Effect Walter was in a dilemma He took time out to define the problem He took time out to define the problem He needed to find something that would have the same effect as carrots for non carrot eating rabbits He needed to find something that would have the same effect as carrots for non carrot eating rabbits He needed to find “The Carrot Effect” He needed to find “The Carrot Effect” But: he didn’t think that he could solve the problem by himself But: he didn’t think that he could solve the problem by himself

14. 14 Dr Lee Gruner- Discovering The Carrot Effect How did Walter define the problem? Current situation A very myopic rabbit A very myopic rabbit A rabbit that causes disruption A rabbit that causes disruption Rominy’s solutions upset the community Rominy’s solutions upset the community A dissatisfied rabbit community A dissatisfied rabbit community Walter not making the right decisions Walter not making the right decisions Stress dealing with the situation Stress dealing with the situation Walter’s leadership being undermined Walter’s leadership being undermined Desired situation Rominy gains perspective Walter makes the right decisions Walter’s stress reduced Rominy and other rabbits live together harmoniously

15. 15 Dr Lee Gruner- Discovering The Carrot Effect How did Walter define the problem? Based on current and desired situation the problem to be solved is: Based on current and desired situation the problem to be solved is: Rominy’s lack of perspective is causing disruption in the rabbit community and hinders decisions being made for the good of all Rominy’s lack of perspective is causing disruption in the rabbit community and hinders decisions being made for the good of all Issue: Rominy has no perspective Issue: Rominy has no perspective Impact: poor decisions being made and community harmony disrupted Impact: poor decisions being made and community harmony disrupted

16. 16 Dr Lee Gruner- Discovering The Carrot Effect How did Walter go about finding the Carrot Effect? To do this he needed the right team with diversity in personality and skills To do this he needed the right team with diversity in personality and skills He needed persistence He needed persistence He needed good data He needed good data He needed to adhere to the principle of “no solutions” He needed to adhere to the principle of “no solutions” He needed to be prepared to take risks He needed to be prepared to take risks

17. 17 Dr Lee Gruner- Discovering The Carrot Effect How does this relate to health? Health is populated with Rominy Rabbits Health is populated with Rominy Rabbits Health is constantly in change internally and externally Health is constantly in change internally and externally Health has many complex problems to solve on an ongoing basis Health has many complex problems to solve on an ongoing basis Health relies on diverse skills and knowledge to solve these problems effectively Health relies on diverse skills and knowledge to solve these problems effectively Health organisations often go about this the wrong way Health organisations often go about this the wrong way

18. 18 Dr Lee Gruner- Discovering The Carrot Effect How does this relate to health? Why do we often end up with unsustainable solutions to problems? Why do we often end up with unsustainable solutions to problems?

19. 19 Dr Lee Gruner- Discovering The Carrot Effect Sustainable solutions need: Sustainable solutions need: Recognition that before we start to solve the problem we need to define the problem Recognition that before we start to solve the problem we need to define the problem Consideration of the impact on the system of both the problem and the solution Consideration of the impact on the system of both the problem and the solution Recognition that the problem to be solved is complex Recognition that the problem to be solved is complex

20. 20 Dr Lee Gruner- Discovering The Carrot Effect Because we want quick solutions: We don’t take the time to define the problem

21. 21 Dr Lee Gruner- Discovering The Carrot Effect Defining the problem Defining the problem Example: The growing dilemma Patient numbers Specialist numbers

22. 22 Dr Lee Gruner- Discovering The Carrot Effect How do you think the Rheumatologists defined the problem?

23. 23 Dr Lee Gruner- Discovering The Carrot Effect What was their initial solution?

24. 24 Dr Lee Gruner- Discovering The Carrot Effect What is the real problem? The Rheumatologists defined it as “not enough specialists” The Rheumatologists defined it as “not enough specialists” The question therefore became “How can we increase the number of specialists?” The question therefore became “How can we increase the number of specialists?” This was translated into “How can we increase the number of trainees?” This was translated into “How can we increase the number of trainees?” This resulted in one solution This resulted in one solution

25. 25 Dr Lee Gruner- Discovering The Carrot Effect The growing dilemma Best case scenario Patient numbers Effective Specialist hours today Effective specialist Hours - future

26. 26 Dr Lee Gruner- Discovering The Carrot Effect What is the question? If you ask the wrong question, you will get the wrong answer If you ask the wrong question, you will get the wrong answer You need to take time to decide what the right question is You need to take time to decide what the right question is

27. 27 Dr Lee Gruner- Discovering The Carrot Effect Defining the problem What is the real problem? What is the real problem? Think about what the major symptoms of this situation are (current situation) Think about what the major symptoms of this situation are (current situation) Think about what you would like to see as satisfactory outcomes (desired situation) Think about what you would like to see as satisfactory outcomes (desired situation) What is the impact on patients of this situation? What is the impact on patients of this situation?

28. 28 Dr Lee Gruner- Discovering The Carrot Effect Defining the real problem Problem needs redefining to enable a sustainable solution Problem needs redefining to enable a sustainable solution Current situation: not enough (specialist) hours allocated to meet patient needs Current situation: not enough (specialist) hours allocated to meet patient needs Desired situation: patients with rheumatology needs appropriately managed Desired situation: patients with rheumatology needs appropriately managed Problem: GAP BETWEEN CURRENT AND DESIRED Problem: GAP BETWEEN CURRENT AND DESIRED PATIENTS WITH RHEUMATOLOGICAL CONDITIONS DO NOT HAVE ACCESS TO APPROPRIATE MANAGEMENT PATIENTS WITH RHEUMATOLOGICAL CONDITIONS DO NOT HAVE ACCESS TO APPROPRIATE MANAGEMENT Major impact of the problem: suboptimal patient care Major impact of the problem: suboptimal patient care THE SOLUTION IS ALL ABOUT HAVING THE RIGHT PERSPECTIVE

29. 29 Dr Lee Gruner- Discovering The Carrot Effect Defining the real problem Analysis: Not enough specialists= not enough time Not enough specialists= not enough time Not enough time= not enough appropriate time Not enough time= not enough appropriate time Appropriate time = deciding whose time is needed Appropriate time = deciding whose time is needed Too many patients= patients who perceive they need a rheumatologist Too many patients= patients who perceive they need a rheumatologist Perception = they need some care but not necessarily specialist rheumatologist care Perception = they need some care but not necessarily specialist rheumatologist care Decision needed on how this care can be provided Decision needed on how this care can be provided

30. 30 Dr Lee Gruner- Discovering The Carrot Effect Gaining Gainingperspective

31. 31 Dr Lee Gruner- Discovering The Carrot Effect What is the real problem? HOW DO WE PROVIDE APPROPRIATE MANAGEMENT TO RHEUMATOLOGY PATIENTS? HOW DO WE PROVIDE APPROPRIATE MANAGEMENT TO RHEUMATOLOGY PATIENTS? Increase the effective workforce Increase the effective workforce Decrease the effective workload (less patients) Decrease the effective workload (less patients)

32. 32 Dr Lee Gruner- Discovering The Carrot Effect Finding the solutions Decrease effective workload Increase effective workforce

33. 33 Dr Lee Gruner- Discovering The Carrot Effect Using the 5 P structure Using the 5 P structure Policies and procedures Policies and procedures People- staff who use the service and supply it People- staff who use the service and supply it Patrons- external users of the service- patients/ relatives Patrons- external users of the service- patients/ relatives Place- facilities and equipment Place- facilities and equipment Provisions- supplies/ consumables Provisions- supplies/ consumables

34. 34 Dr Lee Gruner- Discovering The Carrot Effect Addressing the issues Force field analysis Increase effective workforce Increase effective workforce Decrease effective workload

35. 35 Dr Lee Gruner- Discovering The Carrot Effect Addressing the issues Force field analysis Increasing effective workforce Increasing effective workforce More trainees More trainees Make use of other health professionals Make use of other health professionals Better use of admin staff Better use of admin staff Better systems to improve efficiency Better systems to improve efficiency Work more hours Work more hours Decreasing effective workload Limit reviews Educate GPs better Preventative strategies Educate patients on self-care Patient triage systems Group practice

36. 36 Dr Lee Gruner- Discovering The Carrot Effect Where do the solutions lie?

37. Dr Lee Gruner- Discovering The Carrot Effect 37 This was a complex problem? What does this mean?

38. 38 Dr Lee Gruner- Discovering The Carrot Effect What is a complex problem? Involves many people or groups Involves many people or groups Solution will impact significantly on the system Solution will impact significantly on the system Will have a variety of options for solution Will have a variety of options for solution Will be able to work on many of the options in a multi- pronged approach Will be able to work on many of the options in a multi- pronged approach Will need teamwork and good leadership to solve appropriately Will need teamwork and good leadership to solve appropriately

39. Dr Lee Gruner- Discovering The Carrot Effect 39 The Dysfunctional outpatient service

40. 40 Dr Lee Gruner- Discovering The Carrot Effect The dysfunctional outpatient service The dysfunctional outpatient service Current situation Clinics go 3 hours over time Clinics go 3 hours over time Too many new patients Too many new patients Patients wait 2 hours to be seen and get upset Patients wait 2 hours to be seen and get upset Waiting room doesn’t have enough chairs Waiting room doesn’t have enough chairs Patients’ cars booked Patients’ cars booked Pharmacy makes up chemo without scripts and may need to redo Pharmacy makes up chemo without scripts and may need to redo Day ward overcrowded Day ward overcrowded Desired situation Appropriate numbers of new patients booked Clinics finish on time All chemo made according to scripts No chemo wastage Day ward used more efficiently so no overcrowding Patients happy with the service

41. 41 Dr Lee Gruner- Discovering The Carrot Effect The dysfunctional outpatient service What is the problem? What is the problem? Gap between current and desired situation Gap between current and desired situation Impact Impact

42. 42 Dr Lee Gruner- Discovering The Carrot Effect Definition of a problem- example What is the gap between current situation and desired situation? What is the gap between current situation and desired situation? The overbooking of oncology clinics has a major impact on staff and patients and is compromising patient safety and quality The overbooking of oncology clinics has a major impact on staff and patients and is compromising patient safety and quality Major impact: patient care is compromised Major impact: patient care is compromised

43. 43 Dr Lee Gruner- Discovering The Carrot Effect The dysfunctional outpatient service How do we solve this problem? Decrease the factors leading to the current situation Decrease the factors leading to the current situation Increase the factors leading the desired situation Increase the factors leading the desired situation

44. 44 Dr Lee Gruner- Discovering The Carrot Effect How do we decide which options are best?

45. 45 Dr Lee Gruner- Discovering The Carrot Effect Deciding on the best options Develop a set of criteria and rate according to these as a team Develop a set of criteria and rate according to these as a team Examples of criteria: Examples of criteria: Feasibility Feasibility Time to implement Time to implement Cost Cost Effect on the system Effect on the system Sustainability Sustainability

46. 46 Dr Lee Gruner- Discovering The Carrot Effect What did Walter learn about solving complex problems? You need to take time to understand what the problem is You need to take time to understand what the problem is This means you need to analyse the current situation and be clear on what you want the desired situation to be This means you need to analyse the current situation and be clear on what you want the desired situation to be

47. 47 Dr Lee Gruner- Discovering The Carrot Effect What did Walter learn about solving complex problems? You need to decide what data you need and not try to solve the problem until you have collected and analysed all the relevant data You need to decide what data you need and not try to solve the problem until you have collected and analysed all the relevant data

48. 48 Dr Lee Gruner- Discovering The Carrot Effect What did Walter learn about solving complex problems? Don’t be fooled into thinking there is only one solution and this is “the” solution Don’t be fooled into thinking there is only one solution and this is “the” solution Don’t be fooled into thinking you can use only one option at a time Don’t be fooled into thinking you can use only one option at a time There are many ways of addressing complex problems from many angles There are many ways of addressing complex problems from many angles

49. 49 Dr Lee Gruner- Discovering The Carrot Effect What did Walter learn about solving complex problems? Solving complex problems takes time if you are after a sustainable solution Solving complex problems takes time if you are after a sustainable solution Even then it might not be sustainable in the longer term and constant evaluation is needed Even then it might not be sustainable in the longer term and constant evaluation is needed

50. 50 Dr Lee Gruner- Discovering The Carrot Effect What did Walter learn about solving complex problems? You need the right team