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Dr Lee Gruner- Discovering The Carrot Effect 1
The Art of The Art of Successful Successful
Problem solvingProblem solvingDiscovering the Carrot EffectDiscovering the Carrot Effect
2Dr Lee Gruner- Discovering The Carrot
Effect
Format of workshopFormat of workshop
Introduction to problem solvingIntroduction to problem solving Barriers to problem solvingBarriers to problem solving Understanding complex problemsUnderstanding complex problems Real life examples in healthReal life examples in health Reviewing the principles of solving Reviewing the principles of solving
problems successfullyproblems successfully
3Dr Lee Gruner- Discovering The Carrot
Effect
Why did I write a book about Why did I write a book about how to solve complex how to solve complex
problems?problems?
4Dr Lee Gruner- Discovering The Carrot
Effect
Why did I choose to use Why did I choose to use rabbits as characters rather rabbits as characters rather
than people?than people?
5Dr Lee Gruner- Discovering The Carrot
Effect
The tale of a difficult The tale of a difficult rabbitrabbit
Once upon a Once upon a time, there time, there was a rabbit was a rabbit called called Rominy Rominy
6Dr Lee Gruner- Discovering The Carrot
Effect
Why was Rominy Why was Rominy considered difficult?considered difficult?
He was always rightHe was always right He always had a problem for others He always had a problem for others
to fixto fix He always had the solutionHe always had the solution He never saw anyone else’s point of He never saw anyone else’s point of
viewview He had no perspectiveHe had no perspective
7Dr Lee Gruner- Discovering The Carrot
Effect
The head of the rabbit clan The head of the rabbit clan was Walter Rabbitwas Walter Rabbit
Walter had major concernsWalter had major concerns Rominy always wanted something fixedRominy always wanted something fixed Rominy’s problems were really Rominy’s problems were really
Rominy’s solutionsRominy’s solutions Rominy was very persistentRominy was very persistent Rominy often got his way Rominy often got his way This was causing disharmony in the This was causing disharmony in the
rabbit community as they thought this rabbit community as they thought this was unfairwas unfair
8Dr Lee Gruner- Discovering The Carrot
Effect
Walter was a wise and Walter was a wise and consultative leaderconsultative leader
Walter held regular Walter held regular
sessions on the Old sessions on the Old
Tree Stump to assistTree Stump to assist
rabbits to solverabbits to solve
complex problemscomplex problems
9Dr Lee Gruner- Discovering The Carrot
Effect
Walter was a wise and Walter was a wise and consultative leaderconsultative leader
But he had no idea of how he But he had no idea of how he could solve the problem could solve the problem presented by Rominypresented by Rominy
10Dr Lee Gruner- Discovering The Carrot
Effect
Walter believed in dataWalter believed in data
To find out why Rominy had no To find out why Rominy had no perspective he decided to collect perspective he decided to collect datadata
The one thing that distinguished The one thing that distinguished Rominy from other rabbits was that Rominy from other rabbits was that he was allergic to carrotshe was allergic to carrots
So Walter collected data to see if So Walter collected data to see if this was the issuethis was the issue
11Dr Lee Gruner- Discovering The Carrot
Effect
What did Walter find?What did Walter find? Carrots v visual acuityCarrots v visual acuity
No of carrots
Rominy Rabbit
5 carrots
12Dr Lee Gruner- Discovering The Carrot
Effect
What did Walter find?What did Walter find? Visual acuity and perception were Visual acuity and perception were
directly relateddirectly related Visual acuity was directly related to Visual acuity was directly related to
number of carrotsnumber of carrots Those who ate less carrots had less Those who ate less carrots had less
perceptive qualitiesperceptive qualities Rominy was at the bottom of the scale Rominy was at the bottom of the scale
for visual acuity and perception as he for visual acuity and perception as he ate no carrotsate no carrots
The problem could not be fixed by The problem could not be fixed by feeding Rominy carrotsfeeding Rominy carrots
13Dr Lee Gruner- Discovering The Carrot
Effect
Walter was in a dilemmaWalter was in a dilemma
He took time out to define the He took time out to define the problemproblem
He needed to find something that He needed to find something that would have the same effect as carrots would have the same effect as carrots for non carrot eating rabbitsfor 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 But: he didn’t think that he could
solve the problem by himselfsolve the problem by himself
14Dr Lee Gruner- Discovering The Carrot
Effect
How did Walter define the How did Walter define the problem?problem?
Current situationCurrent situation A A very myopic rabbitvery myopic rabbit A rabbit that causes A rabbit that causes
disruptiondisruption Rominy’s solutions Rominy’s solutions
upset the communityupset the community A dissatisfied rabbit A dissatisfied rabbit
communitycommunity Walter not making the Walter not making the
right decisionsright decisions Stress dealing with Stress dealing with
the situationthe situation Walter’s leadership Walter’s leadership
being underminedbeing undermined
Desired situationDesired situation Rominy gains Rominy gains
perspectiveperspective Walter makes the Walter makes the
right decisionsright decisions Walter’s stress Walter’s stress
reducedreduced Rominy and other Rominy and other
rabbits live together rabbits live together harmoniouslyharmoniously
15Dr Lee Gruner- Discovering The Carrot
Effect
How did Walter define the How did Walter define the problem?problem?
Based on current and desired situation Based on current and desired situation the problem to be solved is:the problem to be solved is:
Rominy’s lack of perspective is Rominy’s lack of perspective is causing disruption in the rabbit causing disruption in the rabbit community and hinders decisions community and hinders decisions being made for the good of allbeing made for the good of all
Issue:Issue: Rominy has no perspective Rominy has no perspective Impact:Impact: poor decisions being made and poor decisions being made and
community harmony disruptedcommunity harmony disrupted
16Dr Lee Gruner- Discovering The Carrot
Effect
How did Walter go about How did Walter go about finding the Carrot Effect?finding the Carrot Effect?
To do this he needed the right team To do this he needed the right team with diversity in personality and with diversity in personality and skills skills
He needed persistenceHe needed persistence He needed good dataHe needed good data He needed to adhere to the principle He needed to adhere to the principle
of “no solutions”of “no solutions” He needed to be prepared to take He needed to be prepared to take
risksrisks
17Dr Lee Gruner- Discovering The Carrot
Effect
How does this relate to How does this relate to health?health?
Health is populated with Rominy Health is populated with Rominy RabbitsRabbits
Health is constantly in change Health is constantly in change internally and externallyinternally and externally
Health has many complex problems to Health has many complex problems to solve on an ongoing basissolve on an ongoing basis
Health relies on diverse skills and Health relies on diverse skills and knowledge to solve these problems knowledge to solve these problems effectivelyeffectively
Health organisations often go about Health organisations often go about this the wrong waythis the wrong way
18Dr Lee Gruner- Discovering The Carrot
Effect
How does this relate to How does this relate to health?health?
Why do we often end up with Why do we often end up with unsustainable solutions to unsustainable solutions to problems?problems?
19Dr Lee Gruner- Discovering The Carrot
Effect
Sustainable solutions Sustainable solutions need:need:
Recognition that before we start to Recognition that before we start to solve the problem we need to solve the problem we need to definedefine the problem the problem
Consideration of the impact on the Consideration of the impact on the system of both the problem and the system of both the problem and the solution solution
Recognition that the problem to be Recognition that the problem to be solved is complexsolved is complex
20Dr Lee Gruner- Discovering The Carrot
Effect
Because we want Because we want quick solutions:quick solutions:
We don’t take the time We don’t take the time to define the problemto define the problem
21Dr Lee Gruner- Discovering The Carrot
Effect
Defining the problemDefining the problem
Example: The growing dilemmaExample: The growing dilemmaPatient numbers
Specialist numbers
22Dr Lee Gruner- Discovering The Carrot
Effect
How do you think the How do you think the Rheumatologists defined Rheumatologists defined
the problem?the problem?
23Dr Lee Gruner- Discovering The Carrot
Effect
What was their initial What was their initial solution?solution?
24Dr Lee Gruner- Discovering The Carrot
Effect
What is the real What is the real problem?problem?
The Rheumatologists defined it as The Rheumatologists defined it as “not enough specialists”“not enough specialists”
The question therefore became “How The question therefore became “How can we increase the number of can we increase the number of specialists?”specialists?”
This was translated into “How can we This was translated into “How can we increase the number of trainees?”increase the number of trainees?”
This resulted in one solutionThis resulted in one solution
25Dr Lee Gruner- Discovering The Carrot
Effect
The growing dilemmaThe growing dilemma
Best case scenarioBest case scenarioPatient numbers
Effective Specialist hours today
Effective specialist Hours - future
26Dr Lee Gruner- Discovering The Carrot
Effect
What is the question?What is the question?
If you ask the wrong question, you If you ask the wrong question, you will get the wrong answerwill get the wrong answer
You need to take time to decide what You need to take time to decide what the right question isthe right question is
27Dr Lee Gruner- Discovering The Carrot
Effect
Defining the problemDefining the problem
What is the real problem?What is the real problem? Think about what the major symptoms Think about what the major symptoms
of this situation are (current situation)of this situation are (current situation) Think about what you would like to Think about what you would like to
see as satisfactory outcomes (desired see as satisfactory outcomes (desired situation)situation)
What is the impact on patients of this What is the impact on patients of this situation?situation?
28Dr Lee Gruner- Discovering The Carrot
Effect
Defining the real Defining the real problemproblem
Problem needs redefining to enable a sustainable Problem needs redefining to enable a sustainable solutionsolution Current situation: not enough (specialist) hours Current situation: not enough (specialist) hours
allocated to meet patient needsallocated to meet patient needs Desired situation: patients with rheumatology Desired situation: patients with rheumatology
needs appropriately managedneeds appropriately managed Problem: GAP BETWEEN CURRENT AND DESIREDProblem: GAP BETWEEN CURRENT AND DESIRED PATIENTS WITH RHEUMATOLOGICAL PATIENTS WITH RHEUMATOLOGICAL
CONDITIONS DO NOT HAVE ACCESS TO CONDITIONS DO NOT HAVE ACCESS TO APPROPRIATE MANAGEMENT APPROPRIATE MANAGEMENT
Major impact of the problem: Major impact of the problem: suboptimal patient suboptimal patient
carecare
THE SOLUTION IS ALL ABOUT HAVING THE THE SOLUTION IS ALL ABOUT HAVING THE RIGHT PERSPECTIVERIGHT PERSPECTIVE
29Dr Lee Gruner- Discovering The Carrot
Effect
Defining the real Defining the real problemproblem
Analysis:Analysis: Not enough specialists= not enough timeNot enough specialists= not enough time Not enough time= not enough appropriate Not enough time= not enough appropriate
timetime Appropriate time = deciding whose time is Appropriate time = deciding whose time is
neededneeded Too many patients= patients who perceive Too many patients= patients who perceive
they need a rheumatologistthey need a rheumatologist Perception = they need some care but not Perception = they need some care but not
necessarily specialist rheumatologist carenecessarily specialist rheumatologist care Decision needed on how this care can be Decision needed on how this care can be
providedprovided
30Dr Lee Gruner- Discovering The Carrot
Effect
Gaining Gaining
perspectiveperspective
31Dr Lee Gruner- Discovering The Carrot
Effect
What is the real What is the real problem?problem?
HOW DO WE PROVIDE HOW DO WE PROVIDE APPROPRIATE MANAGEMENT TO APPROPRIATE MANAGEMENT TO RHEUMATOLOGY PATIENTS?RHEUMATOLOGY PATIENTS? Increase the effective workforceIncrease the effective workforce Decrease the effective workload (less Decrease the effective workload (less
patients)patients)
32Dr Lee Gruner- Discovering The Carrot
Effect
Finding the solutionsFinding the solutions
Decrease effective workload
Increase effective workforce
33Dr Lee Gruner- Discovering The Carrot
Effect
Using the 5 P structure Using the 5 P structure
Policies and proceduresPolicies and procedures People- staff who use the service and People- staff who use the service and
supply itsupply it Patrons- external users of the Patrons- external users of the
service- patients/ relativesservice- patients/ relatives Place- facilities and equipment Place- facilities and equipment Provisions- supplies/ consumablesProvisions- supplies/ consumables
34Dr Lee Gruner- Discovering The Carrot
Effect
Addressing the issuesAddressing the issuesForce field analysisForce field analysis
Increase effective Increase effective workforceworkforce
Decrease effective Decrease effective workloadworkload
35Dr Lee Gruner- Discovering The Carrot
Effect
Addressing the issuesAddressing the issuesForce field analysisForce field analysis
Increasing Increasing effective workforceeffective workforce
More traineesMore trainees Make use of other Make use of other
health professionalshealth professionals Better use of admin Better use of admin
staffstaff Better systems to Better systems to
improve efficiencyimprove efficiency Work more hoursWork more hours
Decreasing Decreasing effective workloadeffective workload
Limit reviewsLimit reviews Educate GPs betterEducate GPs better Preventative strategiesPreventative strategies Educate patients on Educate patients on
self-careself-care Patient triage systemsPatient triage systems Group practiceGroup practice
36Dr Lee Gruner- Discovering The Carrot
Effect
Where do the solutions lie?
Dr Lee Gruner- Discovering The Carrot Effect 37
This was a complex This was a complex problem? problem?
What does this What does this mean?mean?
38Dr Lee Gruner- Discovering The Carrot
Effect
What is a complex What is a complex problem?problem?
Involves many people or groupsInvolves many people or groups Solution will impact significantly on the Solution will impact significantly on the
systemsystem Will have a variety of options for solutionWill have a variety of options for solution Will be able to work on many of the Will be able to work on many of the
options in a multi- pronged approachoptions in a multi- pronged approach Will need teamwork and good leadership Will need teamwork and good leadership
to solve appropriatelyto solve appropriately
Dr Lee Gruner- Discovering The Carrot Effect 39
The The Dysfunctional Dysfunctional
outpatient outpatient serviceservice
40Dr Lee Gruner- Discovering The Carrot
Effect
The dysfunctional The dysfunctional outpatient serviceoutpatient service
Current situationCurrent situation Clinics go 3 hours over Clinics go 3 hours over
timetime Too many new patients Too many new patients Patients wait 2 hours to Patients wait 2 hours to
be seen and get upsetbe seen and get upset Waiting room doesn’t Waiting room doesn’t
have enough chairs have enough chairs Patients’ cars bookedPatients’ cars booked Pharmacy makes up Pharmacy makes up
chemo without scripts chemo without scripts and may need to redoand may need to redo
Day ward overcrowdedDay ward overcrowded
Desired situationDesired situation Appropriate numbers of Appropriate numbers of
new patients bookednew patients booked Clinics finish on timeClinics finish on time All chemo made All chemo made
according to scriptsaccording to scripts No chemo wastageNo chemo wastage Day ward used more Day ward used more
efficiently so no efficiently so no overcrowdingovercrowding
Patients happy with the Patients happy with the serviceservice
41Dr Lee Gruner- Discovering The Carrot
Effect
The dysfunctional The dysfunctional outpatient serviceoutpatient service
What is the problem?What is the problem? Gap between current and desired Gap between current and desired
situationsituation ImpactImpact
42Dr Lee Gruner- Discovering The Carrot
Effect
Definition of a problem- Definition of a problem- exampleexample
What is the gap between current What is the gap between current situation and desired situation?situation and desired situation?
The overbooking of oncology The overbooking of oncology clinics has a major impact on staff clinics has a major impact on staff and patients and is compromising and patients and is compromising patient safety and quality patient safety and quality
Major impact:Major impact: patient care is patient care is compromisedcompromised
43Dr Lee Gruner- Discovering The Carrot
Effect
The dysfunctional outpatient The dysfunctional outpatient serviceservice
How do we solve this How do we solve this problem?problem?
Decrease the factors leading to the Decrease the factors leading to the current situationcurrent situation
Increase the factors leading the Increase the factors leading the desired situationdesired situation
44Dr Lee Gruner- Discovering The Carrot
Effect
How do we decide How do we decide which options are which options are
best?best?
45Dr Lee Gruner- Discovering The Carrot
Effect
Deciding on the best Deciding on the best optionsoptions
Develop a set of criteria and rate Develop a set of criteria and rate according to these as a teamaccording to these as a team
Examples of criteria:Examples of criteria: FeasibilityFeasibility Time to implementTime to implement CostCost Effect on the systemEffect on the system Sustainability Sustainability
46Dr Lee Gruner- Discovering The Carrot
Effect
What did Walter learn What did Walter learn about solving complex about solving complex
problems?problems? You need to take time to understand You need to take time to understand
what the problem iswhat the problem is This means you need to analyse the This means you need to analyse the
current situation and be clear on current situation and be clear on what you want the desired situation what you want the desired situation to be to be
47Dr Lee Gruner- Discovering The Carrot
Effect
What did Walter learn What did Walter learn about solving complex about solving complex
problems?problems?
You need to decide what data you You need to decide what data you need and not try to solve the need and not try to solve the problem until you have collected and problem until you have collected and analysed all the relevant data analysed all the relevant data
48Dr Lee Gruner- Discovering The Carrot
Effect
What did Walter learn What did Walter learn about solving complex about solving complex
problems?problems? Don’t be fooled into thinking there is Don’t be fooled into thinking there is
only one solution and this is “the” only one solution and this is “the” solutionsolution
Don’t be fooled into thinking you can Don’t be fooled into thinking you can use only one option at a timeuse only one option at a time
There are many ways of addressing There are many ways of addressing complex problems from many anglescomplex problems from many angles
49Dr Lee Gruner- Discovering The Carrot
Effect
What did Walter learn What did Walter learn about solving complex about solving complex
problems?problems?
Solving complex problems takes Solving complex problems takes time if you are after a sustainable time if you are after a sustainable solutionsolution
Even then it might not be Even then it might not be sustainable in the longer term and sustainable in the longer term and constant evaluation is neededconstant evaluation is needed
50Dr Lee Gruner- Discovering The Carrot
Effect
What did Walter learn What did Walter learn about solving complex about solving complex
problems?problems?
You need the You need the right teamright team