We are in a historic debate about how and whether to reform the national health system. Of course, ‘reform’ is in the eye of the beholder. What some consider a rational, measured element of a wise reform proposal will appear to others to be a sell-out or, at the other end of the spectrum, ‘socialized medicine in disguise’.

I don’t want to write today about my position on reform. You can get what I think can—and should—be done by e-mail or phone. What I want to explore is how the reform is being done. In other words, I want to talk about how, not what. I want to apply Nolan’s experience in working with “wicked problems” to how Congress and the Obama administration are dealing with reform of a major sector of our economy.

Here are the characteristics of the class of complex problems that earn the title “wicked.” A wicked problem has:

  • No agreed definition of what the problem is;
  • No common definition of what a solution would be;
  • Players who have radically different views of the world and the problem;
  • Continuous change: the symptoms, resources, and constraints of the problem move and change; and
  • No possible solution—but it is possible to get to a point of acceptable temporary discomfort or temporary agreement.

Does this sound like the American health care system? I think it does, and I consider health care reform to be a truly wicked problem.

There is no well-defined theory or strategy for solving wicked problems. In fact, that might be another characteristic of them. Although there isn’t a solution strategy, there is a body of experience about how to work with wicked problems. This body of experience is practitioner knowledge, gained directly from experiences. And as you would expect in 36 years of working in health care, Nolan has practical experience and scar tissue from working with our fair share of wicked problems.

When dealing with a wicked problem, use the following list and apply it to the national health care reform debate by scoring each one a -1, 0, or +1. If you think the national dialog doesn’t reflect this experience factor, rate it a -1. If you can’t tell, mark it a 0. And if the reform debate seems to reflect the experience factor, give it +1. Total your score, e-mail it to us, and we’ll send you a summary of what you thought compared to rankings by other readers.

Here we go!

Facilitate openness. Is there an open or public debate where different stakeholders can voice and explain their ideas? Or are there restrictions in setting, time, or topic that set limits as to which parties can talk about their ideas?

Allow time. Wicked problems take time to be understood or observed and to play out. Is the problem’s solution compressed artificially? Realistically, is there enough time to gather data, form arguments and rationales, and dialog the issues?

Focus on principles before solution tactics. Our experience is that developing agreement on the characteristics of a good solution before jumping to implementation tactics improves results. This gives people with radically different views of the problem and solutions a chance to realize that, in some cases; both parties want the same thing but call it different things. Focusing on principles helps us find a good solution.

Talk about assumptions. Taking time to identify and discuss the assumptions each party has is a good way to air differences and build momentum toward a better understanding. The idea here is not to agree with the assumptions but to understand what they are.

Talk about what has made prior solutions difficult. This gives the different stakeholders a chance to recite their history and world view. And it gives everyone a better understanding of why a reasonable person can hold such a silly idea. Talking about solution history can help identify assumptions, constraints, and resources that may influence the ability and willingness to move forward.

Implement those things for which there is agreement. Implementing a small solution to an aspect of a big problem gives the competing parties a chance to build trust and a common achievement. Frequently, a small implemented agreement can change the parties and the problem.

Plan on repetition. By definition, wicked problems are not solved, but they can be improved to the point of tolerance—this takes a willingness to work on workable issues and to repeat the process as the problem changes. Does the current approach allow for future progress or is the process oriented to a one-time, all-or-nothing, big bang solution?

What’s your score? Send your scoring of the factors to me at merit_smith@renolan or take our short online survey by pasting this URL into your browser - http://tinyurl.com/renolanQ3.

It will be interesting to see what you are thinking. Perhaps we can share our collective thoughts in a way that helps the national debate.