The innovation literature suggests we should pause to think before rushing headlong into solving what we initially perceive to be a problem.1,2 Henry Ford once famously remarked: "If I had asked people what they wanted, they would have said faster horses."
We can fall into this trap when we think about or frame our problems only as the need for more or less of something that we already take for granted in the system. For example, "We need: more resources… less waiting time in our clinic… more 'compliant' patients… better access to traditional services in historically disadvantaged areas."
No doubt, having these things would be an improvement.
But it might also be a good idea to see if we could use existing resources in a more innovative way: eliminate a percentage of clinic visits by providing services through other means, better align our medical advice with patients' lives, or provide care in different ways that are a more natural fit for historically disadvantaged populations.
The Concept of Reframing
Research shows that the language we use to describe an issue influences our thinking.3 Cognitive scientists call this "framing." For example, we might initially frame our issue as: "How can we create more nursing home beds in the community?"
This immediately causes us to think about ways to secure funding and other resources to establish "beds" in a facility that we call a "nursing home." There is nothing wrong with thinking about this, and creating more such beds would likely be an improvement. But such framing could also unnecessarily limit our thinking.
It might also be profitable to explore other—reframed—questions, such as:
- How can we provide great home-based care for patients who need it?
- How can we support families and other caregivers to enable them to competently care for their elderly or infirmed loved ones?
- How can we use technology to enable existing staff in nursing homes to safely care for more patients?
- How can we keep frail patients up and out of bed so that they can better care for themselves?
- How can we identify and better serve patients who are at high-risk for needing nursing home care before their condition deteriorates?
There is no right way to reframe an issue. Using divergent thinking will uncover a variety of ways of looking at a problem to see what new approaches might emerge, rather than simply rushing into problem solving with a traditional statement of the issue. (See: Key Concepts for the Initial Steps of Innovation)
There are a variety of tools that can help better prepare us for innovative thinking. Examples include:
Tool #1: Others' Point of View (OPV)4
Synopsis: List the stakeholders/people with a vested interest associated with an issue and ask
Example in health care: A group working on pediatric asthma initially stated its issue as: "How can we increase children's compliance with the use of inhalers?"
- How might they describe the problem or what is needed?
- What words, phrases, and concepts might they use?
One of the team members asked her 12-year old asthmatic daughter how she would describe the problem and got the following reframed statements:
Similar statements of the issue were generated from the points of view of others, such as parents, school staff and officials, sports coaches, and children who were not asthmatic. These statements were subsequently used in idea generation sessions.
- How can I stop other kids from picking on me and calling me a "druggie" when I use my inhaler?
- I don't like having to go to the school nurses' office to get my inhaler, but the school won't let me keep it in my locker or backpack. What can you do about that?
Tool #2: Pause, Notice, and Observe1,2
Synopsis: Gather a wide variety of facts and observations associated with the issue. Be curious and take nothing for granted. Look both at the problem as it occurs in the health care setting, and at analogous issues faced in other settings. Compile these insights into reframed statements of the issue for use in subsequent idea generation sessions.
Examples of how "Pause, Notice and Observe" can generate innovative problem solving approaches in health care:
1. A hospital had tried numerous approaches to raising staff awareness about infections, with only marginal improvement in infection rates. Unsure of why previous approaches did not produce desired outcomes, clinical leaders decided to pause and charter a team to notice and observe hand hygiene practices throughout the hospital. Among the many things observed were:
Observations from the hand hygiene project were used by clinical leaders to create improvement teams to address the specific aspects of their facility's hand hygiene problem.
- In areas where curtains were used for patient privacy, staff often washed their hands and then pulled back the curtain to access the patient. Cultures performed on the curtains identified numerous organisms.
- Patients and family members who observed staff touching the patient without first washing their hands remarked about this after the staff member left. They reported that they did not feel comfortable speaking directly to the staff member.
2. A large community clinic often experienced long waits in its lab when the number of patients arriving at once overwhelmed the two phlebotomists on duty. The standard statement of the problem—"We need more phlebotomists!"—was met with the predictable response that strained resources did not allow for more hiring.
During her shopping at a crowded grocery store one evening, the clinic manager noticed that when the lines at the registers got long, managers and staff from other sections (e.g., produce, meats) stopped what they were doing to open new registers. She brought this observation back to her clinic and worked with staff and managers to institute a similar system where trained technicians would come from the back of the laboratory to help the phlebotomists process patients at times of heavy demand.
1 Plsek PE. Creativity, innovation and quality. Milwaukee, WI: ASQ Quality Press; 1997.
2 Kelly T, Littman J. The art of innovation. New York, NY: Doubleday; 2001.
3 Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science 1981;211:453-8.
4 de Bono E. de Bono's thinking course. London: BBC Books; 1982.