Asking the Unaskable – Thinking the Unthinkable

Abstract

Posing questions and critically examining the current state of affairs across the spectrum are essential to large-scale quality improvement. The questions we are about to pose are not intended to be gratuitously provocative; they must be addressed to get an accurate assessment of where the system is gridlocked, which interests are aligned or misaligned with a quality agenda and what measures must be taken to move forward. Moreover, the great majority of the questions will come as no surprise to those experienced with the system’s dynamics and frustrated by the inability to act. If we want to accelerate change and improve performance on a larger scale, we have to do things differently. We means the principal actors in the system – governments, regulatory agencies, organizations, boards and senior managers, professional groups etc. All have either legal or moral authority to demand and promote quality care; some have both. Collectively, we have the power to make healthcare accountable for quality and to implement policies and practices that are fully aligned with a quality agenda. A major obstacle to progress is the failure to ask ourselves the wicked questions that will lead to a deep exploration of assumptions we make. Without exploring our assumptions, we will continue to be hostage to our indifference to failure and be unable to reach our improvement potential. Exposing these assumptions can be both uncomfortable and a relief. It is uncomfortable because the conclusions we draw and the beliefs we adopt based on our assumptions often seem to be “the truth” – obvious, acceptable and defensible. They guide us to do and say “the right things.” By engaging people in dialogue, wicked questions invite exploration into inconsistencies in thought that have held us back from achieving our purpose, and can be used to promote a search for local solutions to organizational challenges. This opinion piece poses questions to the main protagonists.