Some issues are so big, so seemingly intractable that it's hard to know the right way to cut into them. In 1973, Horst W.J. Rittel and Melvin M. Webber, professors of design and urban planning at the University of California at Berkeley, referred to these problems as "wicked." A wicked problem has lots of contributing factors, is tough to succinctly describe, and doesn't lend itself to a single right answer. That means a solution is not easily achieved - and in the short-term will likely involve embracing the "less bad" vs. the ideal. Climate change, terrorism, and poverty are all classic examples of wicked problems. Here's one more to add to the list: improving the quality of U.S. health care while lowering costs. Consider the examples below that show the complexity of what we're up against:
- Facilitating fundamental shifts in the way payers, including the federal government, reimburse providers for outcomes instead of services.
- Driving better collaboration and a "continuum of care" among healers from doctors, to nurse practitioners, to dieticians and everything in between.
- Enabling patients to be stewards of their own health by making better lifestyle choices and quarterbacking their care when intervention is necessary.
There are many long-term initiatives underway to begin to address these challenges. Accountable Care Organizations (ACOs) challenge health care systems to sign contracts with Medicare that reward them for decreasing costs (and penalize them if costs increase). Many private insurers are offering similar contractual arrangements to health care systems. Medical Homes charge primary-care physicians to lead teams of professionals, including nurse practitioners, physician assistants, pharmacists, health educators and medical assistants to provide or facilitate comprehensive, coordinated and accessible care for targeted patients. From fit bands to patient portals, there are numerous technology solutions that are making health more of a personal accountability and shifting responsibility away from medical professionals. These, among many others, are fantastic innovations with significant potential to positively reshape American health care. But successful implementation will be years in the making. Adoption at scale will demand incredible cross-organizational coordination. There are countless other change hurdles that we won't even be able to imagine until we're in the thick of the hunt - what my colleagues Nadim Matta and Ron Ashkenas call "white space risks" in their article Why Good Projects Fail Anyway. A realist would say that the odds of success are stacked against us. But looking to times when we've successfully tackled other wicked problems can increase our chances of making a difference.
Housing the homeless is a wicked problem. Like providing better, lower-cost health care, it seems to be the kind of challenge that we'll forever lament, but never really solve. Yet there are organizations that are making a tremendous impact by driving rapid experimentation and learning. The Rapid Results Institute (full disclosure: my company is affiliated with the Institute) continues to achieve incredible results helping homeless veterans get off the streets and into sustainable housing. Here are a few examples of real projects run in partnership with the 100,000 Homes organization:
- Doubled the number of homeless vets moved into apartments in San Diego
- Cut the number of days it takes to find a homeless person a home from 207 to 71 in San Antonio
- Sped up the time it takes to house a homeless vet from 113 to 20 days in Detroit.
I should note that the teams that accomplished these feats did so in about 100 days. Sound too good to be true? It's not - here's more detail from Tina Rosenberg of the New York Times.
In a 2012 HBR blog post discussing this work, Ashkenas and Matta talk about the critical success factors that brought about a surge in performance otherwise unheard of in the fight against homelessness.
Mobilize the ecosystem. "In the work with veterans, plans invariably involved close collaboration and coordination between federal agency leaders, their field staff, local housing authorities, city officials, local NGOs, and other stakeholders."
Making an impact with ACOs, for example, will demand just this sort of ecosystem alignment. Effective ACO consulting starts with robust stakeholder mapping, relationship building, and agreement on the way forward. The key players from provider, payer and patient sides have to understand each other's needs and concerns through open dialogue. At the most basic level, they must agree on the "what" and the "how" - "what" a mutually successful collaboration looks like and "how" they will work together to achieve that vision.
Establish an aggressive 100-day goal. "The 100-day time frame created a sense of urgency - and it also made it easy for team members to temporarily suspend some of the assumptions and mental models that held them back in the past. This spurred a flurry of rapid experimentation with new solutions and new ways of working with each other - and with political leaders."
Continuing with the ACO example, the next step would be to introduce a series of rapid cycle experiments that challenge teams of care providers and managers to achieve highly focused goals in a very short period of time. For example, in 100 days:
- At target hospital X, shift 50 percent of patients regularly using the emergency room for non-urgent care to alternate care sources.
- At health system Y, double the adherence rates among 18-34 year old male patients participating in diabetes management programs.
- At target hospital Z, decrease the cost of end of life care by 25 percent.
Harness the power of peer pressure and support. "The teams also had to persist during the 100-day implementation period - in spite of the difficulties they encountered. They did this through cross-learning, emulation and competition across teams."
The same principles could be applied to a number of care teams going after deep-rooted population health management challenges like those named above as part of an ACO effort. Imagine a scenario in which teams from different hospitals within a single region competed to achieve the best health outcomes at the lowest cost, shared their experiences in virtual roundtables, and earned rewards for applying peer tested best practices.
The Rapid Results Institute's work to end veterans' homelessness provides a workable framework for how to drastically increase the chances of success for solving our wicked health care problem. Like most frameworks, it has to be customized to meet the unique challenges of the health care industry, but the basic building blocks are there. I often tell my clients to steal good ideas -- and to do so shamelessly. In the business world, we call this "leveraging best practices." Here's an open invitation to all those working to improve U.S. health care faster and with bigger impact: steal away.