As part of their PGY3 training, Internal Medicine residents Brian Sanders and Matt Christensen decided to address gaps in medication reconciliation for patients at discharge. Discharge medication reconciliation (med rec) is a complex process that involves multiple teams including pharmacy, nursing, doctors, case management, social work and many others. Med rec’s many steps can cause significant delay and stress for patients and families, both those leaving the hospital and those waiting to get admitted. Reflecting on their own experiences with this process, Brian and Matt realized that the discharge process varied among resident teams. After teaming up with hospitalist Amanda Breviu and watching a few patient discharges from start to finish, they realized that the doctors’ role was complex and likely contributing to variation. But, if they hoped to improve the discharge process, they would need to focus their inquiry and clearly define what specific problem they would address.
What is a problem statement?
problem statement is a clear, concise description of the problem you are trying to solve. A well-written statement allows everyone involved to agree on the problem. Writing a problem statement sounds straightforward—and it can be. Investing your time honing a well-defined problem statement can pay dividends later in the ultimate success of a QI project.
How to write a problem statement
The first step in problem solving is to clearly state the problem.
The following five questions can help guide you through the process of writing and refining a problem statement.
- What is the problem?
- Why is it a problem?
- How does the problem impact the customer and the process?
- When does the problem occur?
- Where does the problem take place?
Follow the Goldilocks principle: Revise until it’s “just right”
Keep in mind that problem statements can be fluid and are often revised and rewritten as you progress through the improvement effort.
Broad statements often need to be made more specific. Large, complex problems often need to be scoped (focus on one part of the problem first). Look for feedback from your team, the people doing the work, and use data (when possible) to help refine.
See it applied
Revisiting our intro case study, residents Brian and Matt examined the discharge process and put some initial thoughts on paper.
Problem Statement Draft #1 — “too big”
“The degree of discharge planning carried out prior to day-of-discharge varies widely for patients on U of U hospital medicine house-staff services. This variation leads to errors on discharge orders (medications, home equipment), prolonged patient waiting in the hospital between leaving and signature of discharge orders, and decreased patient understanding of follow-up plans. Together, these factors put patients at greater risk for readmission, complications for errors in care (particularly medication changes), and delay administration of hospital resources to incoming admitted patients.”
Brian and Matt found that their statement was too broad. The number of factors involved in discharge planning by resident teams was so great that it was difficult to form a logical plan to move forward. At the advice of Amanda and senior value engineer Luca Boi, they decided to focus more specifically on timing of discharge medication reconciliation:
Problem Statement Draft #2 —“too vague”
“The point at which a patient's discharge medication reconciliation varies, and sometimes recurs after the "Discharge To" order has been signed (and thus the discharge medication list has been sent to pharmacy). This variation leads to errors on the printed AVS (after-visit summary), delays in completion of discharge pharmacy processes and related delays in physical patient exit from the hospital. Together, these factors put patients at greater risk for readmission, medication errors, and delay administration of hospital resources to incoming admitted patients.”
With a focus on the timing of discharge medications, the residents went back to the bedside and observed the discharge pharmacist process. Watching the process from the pharmacist perspective helped them deepen their understanding. They further focused their problem statement:
Problem Statement Draft #3 — “just right”
“For controlled substances (opiates), new outpatient prescriptions, if ordered by a resident, must be printed and signed by an attending in order to be valid. Paper opiate orders are frequently not signed with initial discharge medication orders and residents often need to be reminded by discharge pharmacy to get the script. This leads to delays in the discharge process, adds extra work to all providers involved, sometimes leaves patients without needed pain control, and at times cancels a discharge.”
By specifically targeting controlled substances, they were able to move forward and make baseline measurements surrounding controlled substances on discharge.
Using the five questions as a guide, Brian and Matt developed a well-defined problem statement around discharge prescription of controlled substances in an iterative process with feedback from advisors Luca and Amanda.
Keep in mind
1. Be wary of “solution generating”
It is very common to approach a problem with a solution already in mind. Jumping to a solution fails to address the underlying complexity of processes. Use the five questions outlined above to think through and define the problem to avoid solution generating.
2. Lack of a process is not a problem
A problem is not defined by the lack of something specific: “Lack of standard work causes delays.” Problem statements promote broad thinking about all of the factors and opportunities for improvement related to the issue at hand. Instead, focus on outlining gaps in performance: “Variation in the process causes inefficiencies and delays”
The process of making a problem statement can be overwhelming at first but if broken down into the above parts it becomes much easier and more manageable. Avoiding solutions until after this process is done supports better understanding of the problem at hand and minimizes bias in interventions you develop. Following these steps will make your improvement more successful and lay the right groundwork for your your next step.