This document provides guidance on problem solving techniques and tools for health extension workers. It discusses defining problems, measuring their magnitude, generating alternative solutions, and setting objectives. Key steps in the problem solving process include identifying and prioritizing problems, analyzing causes, examining countermeasures, and assessing solutions. Tools that can be used include fishbone diagrams, brainstorming, line graphs and tree diagrams to help analyze problems and their root causes in a systematic way. The overall goal is to implement measurable solutions to identified challenges in healthcare.

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Applying Problem
Solving
Techniques and Tools
for HEW students
By kidist A. (BSc, MPH)

2. Learning outcomes
 Identify and select theme/problem
 Grasp current status and set goal
 Establish activity plan
 Analyze causes of a problem
 Examine countermeasures and their
implementation
 Assess effectiveness of the solution
 Standardize and sustain operation
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3. Introduction cont ….
What is problem ?
 Anything that deviates from the standard
or target.
 A gap between actual and desired
conditions .
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Desire /ideal
situation
Current
Gap =problem

4. Introduction cont …
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What is Problem Solving
 Problem solving is a process to identify a
challenge or barrier to high quality care and
implement and evaluate measurable solutions
to the identified problem.
 It is a systematic way to break down complex
issues into tangible solutions.

5. Problem solving ….
 Problem solving is the act of
◦ defining a problem;
◦ determining the cause of the problem;
◦ identifying, prioritizing, and selecting
alternatives for a solution; and
◦ implementing a solution.
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7. Define problem
 Differentiate fact from opinion
 Specify underlying causes
 Consult each faction involved for
information
 State the problem specifically
 Identify what standard or expectation is
violated
 Determine in which process the problem
lies
 Avoid trying to solve the problem without
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8. Generate alternative solutions
 Postpone evaluating alternatives initially
 Include all involved individuals in the
generating of alternatives
 Specify alternatives consistent with
organizational goals
 Specify short- and long-term alternatives
 Brainstorm on others' ideas
 Seek alternatives that may solve the
problem
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9. Evaluate and select an
alternative
 Evaluate alternatives relative to a target
standard
 Evaluate all alternatives without bias
 Evaluate alternatives relative to
established goals
 Evaluate both proven and possible
outcomes
 State the selected alternative explicitly
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10. Implement and follow up on the
solution
 Plan and implement a pilot test of the
chosen alternative
 Gather feedback from all affected
parties
 Seek acceptance or consensus by all
those affected
 Establish ongoing measures and
monitoring
 Evaluate long-term results based on
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11. Benefits of Structured Problem
Solving process
Remove time lost in debate
Identify weak points in processes
Discover systemic causes
Explain with reasons why an incident
occurred
Gives a real representation of the incident
Compare what actually happened against
what should have happened, at any point
during the incident.
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12. Importance of problem selection
Many problems happen everyday in
working place
All problems cannot be solved at once
Identification, prioritization and focus
is necessary
Resources are limited
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21. How to solve problems?
-The Problem Solving process is based upon
PDCA CYCLE
- Plan, Do, Check & Act
Where to Identify the Problem ?
 Problems you are facing in your workplace
 Things you want to improve to make your
work effective and efficient
 Issues raised or claimed from your internal
and external client
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22. Who should select theme？
Who knows what is happening on the ground?
 The staff working in the section.
Process for theme selection.
1.Staff meet to brainstorm about problems in
their current working place (Clarify problem
statement)
◦Issues and problems in their working
environment
◦Complicated work processes/procedures
◦Clams from internal and external clients
◦ Accident, errors often happening
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23. Process for theme selection conti…..
2. List up all raised issues and problems
Note :
- Do not seek contributing factors and causes
of the problems
- Do not blame and deny others’ opinions
3. Categorize listed issues and problems into
two
categories;
1) Possible to solve immediately
2) Impossible to solve immediately
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24. Process for theme selection cont…
4. Action should be taken immediately for the
issues Possible to solve immediately
5. Check feasibility of all the problems for those
which are Impossible to be solved immediately
 Possible themes need to be checked its
feasibility by impact, urgency, possibility,
resource availability.
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25. Process for theme selection cont…
Impact
What is the impact, when it is
implemented?
Is it possible to get impact with little
inputs?
Urgency
Do we have to do it immediately?
Possibility
Is it possible to complete whole process
within 6 months?
Is it possible to carry out this process
within your department?
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26. Process for theme selection cont…
 Resources
Possible to implement with existing
resource?
Require involvement of many sections?
Is data and information available for
situation analysis?
 If not available, is it possible to
collect?
Who and how many staff are going be
involved?
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28. Case 1: Overcrowding-Surgery ward
• Surgical Ward of Y hospital has 87 beds.
Staff complain to management that there is
overcrowding and that the 87 beds are
always occupied which forces them to use
beds from other wards.
• After receiving the complaint, hospital
management immediately decided to get
more beds for the surgical ward.
What would you do?
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29. Case 2: Long Waiting Time
• X health Center received complaint from
the community that there is long waiting
time at OPD.
• Health center management conducted a
meeting to review complaints and decided
to write a letter to the Woreda requesting
financial support to build two additional
consultation rooms to alleviate the problem
of long waiting time.
What would you do?
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30. What Is Problem Solving?
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Current State
(Problem)
Future State
(Vision/Objective)
STRATEGY

31. Problem statement
 A problem statement is a statement of a current
issue or problem that requires timely action to
improve the situation.
 A problem statement is a concise description
of the issues that needs to be addressed
Good problem statement should:
1. Focus on a single problem
2. Do not state the cause or the solution; focus
on the problem
3. Be brief
4. Address problems that are feasibly solved
5. Ensure the problem is shared widely by key
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32. Examples of good problem
statements
• There is a high rate of neonatal mortality at
the health center.
• Medical records cannot be located in the
health center.
• The waiting time for outpatient clinic is long.
• There is no ambulance service in the
Woreda.
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33. Exercise 1 problem statement
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“Lack of budget support from the woreda to
maintain water supply in the emergency room”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion:
“emergency room does not
have water supply”

34. Exercise 2 problem
statement
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“Our budgets are too small and we run out of HIV
test kits in the middle of the year, and our health
officer has left, along with 3 other workers, and
clients are not very happy with our service”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion: correction
1. We have a poor supply chain for
HIV test kits.
2. Staff turnover is too high.
3. Clients are dissatisfied with our
services.

35. Exercise 3 problem statement
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“Our referral system is vertical. We receive from
the health centre (referral in) and refer out to
secondary hospital if beyond our hospital capacity.
So the weakness is our hospital is not giving the
feedback to the referred facility and not receiving
/collecting /feedback from the referred hospital.”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion:
“Feedback documentations
are not provided to referring
facility”

36. Exercise 4 problem statement
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“HEWs are not motivated to work. We need
to increase supervision to improve the
number of graduating model households in
the woreda”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion: the correct
“Low number of model
households graduating by
HEWs”

37. Exercise 5 problem statement
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“Spare parts are not available in Ethiopia, so a lot
of medical equipment at the health center are not
functioning”
Single problem
No cause/solution
Brief
Feasible to solve
Agreed by others
Suggestion:
“High rate of non functional
medical equipment in the health
center” or
“Broken medical equipment's in
the health center are not being
repaired”

38. Magnitude of the problem
Why we need to measure the magnitude?
1. To know if the problem is really a problem
2. To have baseline measure to set objective
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39. Measuring Magnitude
• There is a high rate of neonatal mortality
at the health center.
 What is the neonatal mortality rate?
• Medical records cannot be located in the
health center
 Percent of medical records not located?
• The waiting time for outpatient clinic is
long
 What is the waiting time at the outpatient clinic?
• There is low ANC coverage in the woreda
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40. Tools used in Problem Solving
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41. Cont..
 The above images in order are
1. Line graph
- Visualization of measurements
- Upper & lower specification limits +
mean
-Location of measurements helps
analysis
2. Brain storming
- No judgment or criticism
- Quantity over quality
- Keep using previous ideas as stimuli
for new ideas 12/28/2022 41

42. ROOT CAUSE ANALYSIS
- Then we add headers for: “Man”, “Method”, “Material”,
“Machine”,
“Measurement”, and “Mother Nature” (Environment)
3. Fish bone
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Effect
Environmental
Man
measurement Mother nature
Material
Machine

43. 4. The Tree Diagram
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Effect
Why?
Why?
Why?
Why?
Why?
Why?

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45. Session –Two
Setting objectives
LO2.Grasp current status and set
goal:-
. Defining extent of problem
. Setting appropriate and achievable goal
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46. Step 2. Set Objectives
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Current state
(problem)
Desired state
(objective)

47. Cont..
 Once the problem has been clearly defined, the
problem statement can be translated into an
overall objective, or main goal.
 This is the goal that your team will focus all of
your efforts on, so it is important that it is clearly
defined.
 Good overall objectives
◦ Address the problem statement
◦ SMART
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48. SMART objectives
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SPECIFIC– What exactly are we
going to do?
MEASURABLE– Can we measure
it?
ACHIEVABLE– Can we get it done
in time? With available resources?
RELEVANT – is it inline with the
vision and priorities of the MOH?
TIME-BOUND – When will we
achieve our goal?
Problem: Long
waiting time in
OPD
Objective:
Reduce OPD
wait time by 30%
in 6 months

49. Cont…
GOOD or BAD
 = We will improve the way we handle
complaints
 = We will reduce the number of
complaints by 10% by next FY
 = We will increase our service
coverage from 75% to 85% in next FY
by end of Q3
 = We will increase our sales next FY
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50. Exercise 2 – Objective Statement (30
minutes)
1. Review background information and
problem statements
2. Propose a SMART Objective
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51. Exercise 2. Suggest an objective for:
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Background Information: Alem woreda often
reports in accurate HMIS data. The woreda has the
high mortality rate in emergency room at 55%.
HMIS department claims that this is due to skill gap
of staff.
Problem statement: Alem woreda frequently faces
inaccurate case management .
Objective: To decrease the emergency case
mortality in emergency room of Alem woreda from
55% to 30% by the end of 2016.

52. Exercise 2. Suggest an objective for:
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Background Information: Tena Health Center
reported that only 10% of pregnant women in its
catchment area have completed the required 4
ANC visit (ANC+4). MOH has set a national goal
of reaching 50% ANC+4 coverage by July 2016.
Problem statement: Low coverage rate of four
ANC visits in Tena Health Center.
Objective: To increase the percentage of
pregnant women completing 4 ANC visit from 10%
to 50% by July 2016.

53. Exercise 2. Suggest an objective
for:
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Background Information: Woreda official have
realized that Tena Health Center refers patients to
Beza primary hospital but never receives feedback.
The Woreda plans for this to change and feedback
after referral to at least reach 70%
Problem statement: Feedback is not provided to
Tena Health Center following referral.
Objective: To increase the percent of referral-
feedback received by Tena health center from
Beza hospital from 0% to 70% by July 2016.

54. Session=THREE
Analyze causes of a problem
Objectives of the session :-
 Listing all possible causes of problem
 Analyzing cause relationships using4M1E
 Identifying causes of the problems
 Selecting root causes
 Listing all possible ways using creative
idea generation
 Testing and evaluating suggested
solutions
 Preparing detail summaries of the action
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55. Determine Root Cause
Why Root Cause Analysis?
 To solve problems on structural basis
 To ensure problems do not return
 To ensure sustainable improvements
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56. Step 3: Root Cause Analysis
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It is a step by step process that:
• answers the question, “why is this problem
happening?”
• finds the true origin of the problem
It is important to ensure we:
• solve the problem permanently
– treat more than just the symptoms of the
problem
What is a root cause analysis and why should
we conduct one?

57. r
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58. Steps for successful RCA
1. Assemble a knowledgeable team
2. Start with a descriptive statement of the
incident/near miss
3. Use Root Cause Analysis techniques
4. Determine what conditions, events,
and/or factors might have caused the
incident
5.Prevent skipping levels or jumping to
conclusions
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59. How do you do root cause
analysis?
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Collecting possible root
causes
A
Verify
B
Identify real root cause
C

60. First, collecting possible root causes & opinions
(brainstorm, interview, focus group…)
• Discuss with involved staff
• Ask them about the causes to the problem
• Allow them to provide their opinion
• Record the “suggested” root causes using
“Fishbone”
A
How do you do root cause
analysis?
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61. Root……
 Several tools could be used in the process
of root cause analysis, such as " 5 Ms &
E" the abbreviation stands for "Manpower,
Machine, Measurement, Material,
Methods and Environment“
 it is a technique where you ask questions
about the 5Ms & E till you find the root
cause of the problem
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63. Environment
Measurement
Material
Not motivated
Small space
MR misplaced
No filing system
Loss of MR
man
Patient don’t remember
MRN
No training in
filing system
No method to find MRN
Bad shelves, difficult to
locate file
Fishbone diagram
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66. How do you do root cause analysis?
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-Next, verify each “suggested” root cause.
-Collecting evidence using different tools
Verify and prioritize
-This verification step is the most analytical
part of the root cause analysis. Which tools
should you use?
-A robust root cause analysis usually requires
the use of a few tools together.
B

67. Tools to collect evidence
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Flow chart
Pareto diagram
Mapping
Time study
Questionnaire
Tally
Others
Many methods/tools can help to collect evidence to
identify the real root cause(s)
Data

68. When to use which?
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• To collect initial perspectives
Fishbone
- Flow chart
- Mapping
-Pareto diagram
-Tally
Line graph
Time study
Questionnaire
• To understand the work process
• To present frequency data for
comparison
• To compare trend
• To understand the time required to move
through a process
• To organize opinion into quantifiable data

69. Begins
Process
Decision
Process Process
End
Yes No
Enter
restaurant
Read
menu
Enough
money?
Buy
Kitfo
Leave
Buy
Tea
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Flow charts

70. Advantage of flow charting
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• Describes complex processes in
manageable steps
• Identifies any breakdowns
• Shows how one’s own actions
influence “downstream” events
• Helps generate alternative
approaches

71. Pareto diagram
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72. Advantage of Pareto Diagram
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• Quantifies information
• Provides data so you can prioritize
 focus on biggest issues first
• Useful tool for showing progress

73. Advantage of mapping
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• Describe complex spatial
relationship in clear visual
manner

74. Time Study
Measure times of a process
Eg. Time study can be used to study waiting
time & process time of a given event
• Wait time
From time the patient arrived to the time
service was provided
• Process time
Time used to provide the service
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75. Patient enters
pharmacy
Patient gets
medication
Wait time
Process time
Total time
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76. Advantage of time study
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Value
• Provide quantified data
• Extremely useful in problems
related to “time”
• Useful tool for showing progress

77. Advantage Tally sheet
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• Quantifies information
• An easy, simple form used to “count”
occurrence
in real time for simple situations

78. Questionnaires
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A tool consisting of a series of questions for
gathering information from respondents.
Advantage
• Able to quantify qualitative data
• Collect and gather “opinion”

79. D. To find out which staff has taken
the most day off
Fishbone
Flow chart
Pareto diagram
Mapping
Time study
Questionnaire
Tally
B. To understand the IP
admission process
E. To initiate an investigation
G. To understand how the cashier
location affects OP traffic
F. To find out waiting time for
surgical clinic consultation
C. To investigate patient
satisfaction
A. To calculate the % of HIV
patients completed ART course
Exercise 3 -When to use which?
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80. Session -4.
Establish activity plan
Objectives of the session :-
 Develop different alternative interventions
 Compare each strategy standard .
 Select your best intervention
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81. Steps 4-6
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4: Develop different alternative interventions
5a: Set criteria for comparison
5b: Create table for comparison (matrix)
5c: Compare each strategy criterion by criterion
6: Select your best intervention

82. List ALL the possible solutions you might
use to address the root cause(s)
Good interventions:
 Address the most important and feasible
root causes
 Use existing resources if possible
 Have some degree of flexibility
 Think about possible unintended
consequences
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4: Develop different alternative
interventions

83. - Avoid the temptation to do
everything
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84. The common criteria's are
Effectiveness (Impact): What is the probability
that it will work?
Time to effect: How long will it take to work?
Feasibility: Is there capacity and stakeholder
support?
Annual Cost: How expensive is it to carry out?
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5a: Set criteria for comparison

85. 5b: Create table for comparison
(matrix)
Strategie
s
Criteria Impact Cost Time Feasibilit
y
Strategy
1
Strategy
2
Strategy
3
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5c: Compare each strategy criterion
by criterion
Evaluate with qualitative and quantitative
data
Listen to reason and intuition
Impact Cost Time Feasibilit
y
Strategy
1
Strategy
2
Strategy
3
5- most ideal; 1 – least ideal

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6: Select your best strategy
Impact Cost Time Feasibilit
y
Total
Strategy
1
5 3 4 3 15
Strategy
2
4 4 2 3 13
Strategy
3
1 2 1 2 6
Be clear on choice and communicate it

88. Short comings of decision matrix
 Estimates are not precise typically,
so judgment is required.
 The matrix gives guidance only.
 There is always uncertainty.
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89. Example
Problem: Toilets are always dirty
Objective: Ensure all toilets are always clean in the
coming 6 month.
Root cause: toilets are cleaned only 3 times a day and is
not sufficient for the high patient volume usage
Alternative Interventions
1. Increase # of cleaning staff
2. Increase frequency of cleaning
3. Lock toilet and supervisor keeps the key
4. Adjust frequency of cleaning according to
patient volume
5. Supervisor station in toilet to supervise usage
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90. Key Summary
 Create good interventions that address the most
important and feasible root causes
 Set clear criteria that are important to
implementation
 Create matrix to compare criteria by criteria
 Compare objectively as well as using common
sense
 Select and communicate the best strategy to
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91. Session .5.
Develop implementation plan and
implement
Objectives
 Implementing action plan
 Monitoring Implementation and
checking activities
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92. Strategic Problem Solving
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8-Step Method
1. Define the problem
2. Set the overall objective
3. Conduct a root cause analysis
4. Generate alternative interventions
5. Perform comparative analysis of
alternatives
6. Select the best intervention
7. Develop implementation plan and
implement
8. Develop evaluation plan and

93. Implementation Plan
 Why do we need an implementation
plan?
 What should be included in the plan?
 How do you communicate the plan to
other people?
 What if other people do not want to
engage (resist your proposed change)?
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94. Step 7 Implementation Plan
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Step 7a: Create a detailed list of tasks/activities
Step 7b: Estimate the time required for each task
Step 7c: Sequence the tasks/activities
Step 7d: Identify a person(s) responsible, Resources
required
Step 7e: Use Gantt chart format for the project plan

95. Step 7 Implementation Plan
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 In order to complete a project, there are many
tasks/activities/steps to do, what are they?
Step 7a: Create a detailed list of tasks/activities

96. Step 7 Implementation Plan
 How much time does each task need?
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Step 7b: Estimate the time required for each task

97. Step 7 Implementation Plan
 Why is sequencing important?
◦ Some tasks need to be done before others can happen
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Step 7c: Sequence the tasks/activities

98. Step 7 Implementation Plan
 Who is the person responsible to do the
task
 Match the tasks and skills and
convenience
 Identify resource requirements
(materials, people budget)
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Step 7d: Identify a person(s) responsible,
resources required

99. Step 7 Implementation Plan
• Use the plan to monitor progress
• Change the plan regularly to keep it
realistic
• Use it to update and communicate to
others
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Step 7e: Use Gantt chart format for the project
plan

100. Gantt Chart example
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Tasks
People
Responsible
Timeline &
Sequence

101. Strategic Problem Solving
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8-Step Method
1. Define the problem
2. Set the overall objective
3. Conduct a root cause analysis
4. Generate alternative interventions
5. Perform comparative analysis of
alternatives
6. Select the best intervention
7. Develop implementation plan and
implement
8. Develop evaluation plan and evaluate

102. Step 8: Evaluation & monitoring
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 Why evaluate?
 How will you know if your problem has been
solved?
 How will you know if your implementation is
working?
 How will you know if the implementation is not
creating negative effect?

103. Continuous monitoring
 Indicators help to measure results
Good indicators should be:
◦ Reliable
Regardless who is measuring it, the result
should be the same
◦ Feasible
Possible to measure with the available
systems and resources
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104. Are these indicators appropriate?
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1. Objective: To increase completeness of nurse
care plan
Indicator: # nurses trained in documentation
2. Objective: To increase number of functioning
toilets
Indicator: Percentage of functioning toilets
3. Objective: To decrease OPD wait time
Indicator: # physician started clinic on time
Are these process or outcome indicators?

105. Example
Problem: high hospital acquired infection rate
Objective: To reduce HAI from 55% to 25% by
Aug 2016
Indicators Pre
intervention
Post
intervention
Existance of policy on
infection control
No Yes
Staff trained on infection
control
35% 65%
HAI Rate 55% 25%
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115. Thank You!
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