Over the last few months I have noticed the term ‘wicked problems’ being used more and more in relation to healthcare. In particular those who work in quality improvement are using it as a term to describe quality or safety problems.
It is a term that doesn’t sit right with me; apart from the ‘evil’ connotation and the unnecessary addition to our language I don’t think it readily applies to quality and safety.
Rittel and Webber wrote in 1973 that wicked problems have ten characteristics (thanks to wikipedia.org):
- there is no definitive formulation of a wicked problem
- wicked problems have no stopping rule
- solutions to wicked problems are not true or false, but good or bad
- there is no immediate and no ultimate test of a solution to a wicked problem
- every solution to a wicked problem is a ‘one shot operation’ because there is no opportunity to learn by trial and error as every attempt counts significantly
- wicked problems do not have an exhaustively describable set of potential solutions, nor is there a well described set of permissible operations that may be incorporated into the plan
- every wicked problem is essentially unique
- every wicked problem can be considered to be a symptom of another problem
- the existence of a discrepancy representing a wicked problem can be explained in numerous ways, the choice of explanation determines the nature of the problems resolution
- the social planner has no right to be wrong
I need to understand more about what this list means, it all seems a bit mind boggling to me – but if I take one or two of the above list it does not fit with what I know about quality and patient safety:
there is no immediate and no ultimate test of a solution to a wicked problem? we know about tons and tons of solutions for patient safety – they just have not been implemented yet
every solution is a one shot operation because there is no opportunity to learn by trial and error? surely that is what we do all the time, test something, adapt it, make it work for the local context and yes it may fail and sometimes we have to stop doing it because it has been found never to work – but this is still trial and error
every wicked problem is essentially unique? the same or similar human error, mistakes, system and human factors, incidents happen repeatedly across the NHS in all care settings – they are sadly not unique but because they are not unique provide an opportunity to make a big difference if addressed
solutions to wicked problems are not right or wrong? odd – are we not trying to find the right solutions to our quality and safety problems
The literature goes on to describe wicked problems as ‘a problem whose solution requires a great number of people to change their mindsets and behaviour’ – examples include global climate change, the aids epidemic, pandemic influenza, international drug trafficking and social injustice. If we view avoidable harm as ‘a problem whose solution requires a great number of people to change their mindsets and behaviour or an epidemic I can see how this would fit into this description but I would simply call that a large scale complex or cultural problem rather than a ‘wicked problem’.
Am I just being picky about the words? I suppose I am. But what worries me is that we can isolate people by trying to use different words, and we can paralyse action if people don’t truly understand what they can do in a clear, easy and simple language. In the same way as management speak, or acronyms – we can alienate. In the case of ‘wicked problems’ being assigned to quality and safety issues in healthcare we risk alienating not only frontline clinicians but more importantly patients and their families.