Addressing “Wicked Problems”: The Board’s Role

Countless articles over the past two years have explored the impact of the COVID-19 pandemic on seemingly every facet of our healthcare system—declining hospital and physician office volumes concurrent with intense capacity pressure elsewhere in the system; severe workforce challenges across the spectrum from physicians/clinical staff to lower-skilled employees; scrutiny around the diversity, equity, and inclusion of leadership, staff, and the patients we serve; and increasing pressure to address pressing community health needs.

Although the pandemic certainly accelerated or exacerbated the above challenges, it also has exposed the myriad structural issues at their heart. Longstanding challenges also have begun to collide with new ones emerging as the mission of healthcare systems and hospitals increasingly is reframed from “providing excellent, patient-centered care to [predominantly sick] patients” to “providing value over volume, improving health, resolving health inequities, and addressing the social determinants of health in our communities.”

For instance, COVID-19 has disproportionately affected communities with high levels of poverty and underlying health conditions, filling needed beds and intensive care units while at the same time driving down hospital volumes/revenues from elective procedures that often subsidize crucial care for the same at-risk populations. Clearly, our community mission calls us to address these larger societal issues—but how, when most of our payments still are based on care encounters that typically begin when a patient walks through one of our myriad front doors, whether virtual, physician office, ambulatory center, or the hospital itself?

What Are “Wicked Problems”?

As this example illustrates, the collision of traditional and new challenges for hospitals and health systems has created what may be considered “wicked problems,” that is, problems that are hard or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize.

While these problems can seem overwhelming, the first step toward addressing any of them is to recognize that no hospital or system, regardless of its size and financial strength, can effectively address a wicked problem alone but instead must build effective strategic partnerships or collaborative relationships to tackle them together. This article focuses predominantly on creating effective, durable relationships.^[1]

Don’t Be Afraid to Tackle Wicked Problems

Most wicked problems are systemic and have been building for years or decades (e.g., enormous predicted shortages of physicians and staff). But they won’t go away on their own, and if they could impair your long-term vision or viability, we recommend that, working with management, the board:

1. Identify your organization’s most pressing “wicked” problems. Identify the one or two top-priority complex problems for which a local, regional, and/or national collaborative relationship may help meet a strategic goal (e.g., improve maternal-fetal health outcomes both by partnering with trusted community leaders and local FQHCs and participating in a national, grant-funded pilot program; create a pipeline for a diverse future workforce by developing relationships with local high schools, youth groups, and community colleges). Understand that a partnership is a vehicle to address a wicked problem; it is not an end in itself.
2. Honestly assess how desirable a collaborative partner you would be to others. Do local or regional leaders/organizations trust you? Is your hospital or system known to be collaborative, or does it default to a “command and control” approach? Do providers of grant funding know about you; would your presence in a collaborative increase the likelihood of obtaining such funding? Identify what, if any, cultural changes could make your organization more attractive to potential collaborative partners, including payers or granting agencies/foundations.
3. Clearly define your organization’s role in collaboratively addressing a wicked problem. Most collaboratives value consensus and risk having “too many cooks in the kitchen.” At the outset, clearly define your primary role(s) within the group: as a catalyst, convener, leader, or active participant. The roles of other participants should be similarly clear and agreed upon. The hospital or system should avoid being viewed primarily as a funder with deep pockets.
4. Recognize that collaboration will consume valuable executive leadership time. Decision-making often is slow, sometimes glacially so, in a strategic partnership. With management already overstretched, the board needs to heed the CEO’s advice about which potential relationships are worth the effort. There should be a return—demonstrable progress in addressing the wicked problem—that justifies the investment of time and any monies.
5. Anticipate at the outset the potential for “sunsetting” the collaborative partnership. While wicked problems, sadly, are long-lasting, that does not mean that a partnership should continue indefinitely. Like many “mission-related” initiatives where no financial return is expected, collaboration can take on a life of its own. Consider entering into a time-limited relationship wherein all parties agree to reassess its value at a specified point. This can both foster greater accountability and allow a participant to drop out gracefully.

Conclusion

Hospitals and systems are facing more “wicked” problems than ever. Meeting these challenges alone is no longer an option. Boards have a responsibility to help their organizations explore and oversee new partnerships to meet their strategic goals. With clear-eyed, skilled executive leadership and a supportive board, organizations can cultivate partnerships that will help them meet the myriad challenges of a future healthcare system that likely will look very different from today’s.