Fishbone Diagram: A Tool To Organize A Problem's Cause and Effect
Problems. We all have them. Whether it鈥檚 a check engine light or an adverse patient safety event, we first need to discover what鈥檚 causing the problem before trying out solutions. Senior Value Engineer Luca Boi and a team of Oncology residents get to the root cause using a fishbone diagram.
By Luca Boi | 2 minutes
LEARNING OBJECTIVES
After completing the lesson you will be able to:
- Define root cause analysis (RCA)
- Demonstrate RCA using a Fishbone Diagram
CASE STUDY
At an Huntsman Cancer Institute Clinic, providers are often delayed in how soon they see a patient during a new visit appointment. Typical delays (wait time) from check-in to provider page was 20 minutes. This 20-minute delay presented a cascade of problems for patients and care teams. For patients, it limited face-to-face time with a provider. For residents, the lack of time hindered care - building rapport with patients, potentially missing important details that help inform the care plan. The delay also caused resident job dissatisfaction. To identify all the moving parts in this complex (yet seemingly simple) problem, the team turned to the fishbone diagram as a useful tool to investigate the multiple causes of delay.
HEALTH CARE'S PROBLEM SOLVING TOOLKIT
In health care, we rely on evidence-based methods for solving problems. Root Cause Analysis (RCA) is a collective term that describes a wide range of approaches used to investigate a problem and its causes.
When we talk about a problem we often refer to its impact. We know how it impacts us personally, our system, patients, and/or customers. But our experience of the problem鈥攊t鈥檚 impact鈥攄oesn鈥檛 really tell us why it鈥檚 happening鈥攖he cause. If we don鈥檛 know the cause, we won鈥檛 be able to prevent it from happening again. Investigating a problem and its causes can result in long-term solutions, which is an essential part of our patient safety journey.
FISHBONE DIAGRAM
AN EASY TO USE TOOL FOR CONDUCTING A ROOT CAUSE ANALYSIS
鈥媁hat it is: The fishbone diagram is a tool to organize ideas and theories about what causes a problem or an event.
How it works: Teams work together to brainstorm and identify potential causes and group them into several categories to help highlight potential issues. Frequently used categories include people (or patients/providers/stakeholders), culture, method (or process), technology, equipment, supplies, etc. (customize categories as needed).
FOLLOW FOUR STEPS TO FISHBONE
Step 1:
Write down the problem you are trying to solve.
Step 2:
Identify as many categories (or contributing factors) to the problem you can. Start with 4-6 main categories and expand as needed.
Step 3:
Brainstorm possible causes of the problem and place them under the categories where they fit best.
Step 4:
Prioritize what causes you should address first. Select 1-3 causes that will have the highest likelihood to solve the problem by considering feasibility (cost, support, timeframe, etc.) and likelihood to succeed.
THREE TIPS FOR FACILITING A FISHBONE
A successful fishbone diagram is led by a facilitator鈥攐ne individual on the team who鈥檚 job is to remain impartial to the discussion, write down the identified causes on the fishbone diagram, and let the participant discussion flow freely.
Here are the top three tips for leading a successful fishbone:
#1. HELP THE TEAM FOCUS ON IDENTIFYING CAUSES, NOT SOLUTIONS
It鈥檚 common for people to brainstorm solutions (how to fix), rather than causes (what to fix). Simply acknowledge any comments by writing them to the side (don鈥檛 disregard any comments, it鈥檚 demoralizing) and help everyone remember the difference between the two. For example, if the problem is delays at patient check-in, 鈥渁dd front desk personnel鈥 offers a solution (how to fix). Whereas 鈥渇ront desk is short-staffed鈥 focuses on a potential cause (what to fix).
#2. THE CAUSE IS MORE IMPORTANT THAN THE CATEGORY
People often get confused or stuck on what category a cause should go into. As a facilitator, remind the participants that listing the cause is more important than where it goes. For example, 鈥渇ront desk is short-staffed鈥 could be placed under the category of People, but also Culture.
Sometimes a main category can become too big. A common one is to start with the 鈥淧eople鈥 category, but by the time 10 causes are identified under that category, you may choose to split it, for example as: 鈥淣urses鈥 and 鈥淒octors.鈥
#3. KEEP BRAINSTORMING UNTIL THE IDEAS RUN OUT
People are often unsure of how many causes to identify. As long as the discussion keeps going, people are still brainstorming. When the silence starts to creep in, you have your first clue that perhaps you have enough to get started.
As facilitator, you will write the statements as they come out during the discussion. If you have to paraphrase what was said (because of space requirements, complexity, etc.) confirm with the group that what you wrote was what was said.
SEEING IT APPLIED
Returning to our introduction case study, the Oncology residents first mapped the process to identify where it was breaking down. They then brainstormed as a team and came up with the following categories and causes.
HCI HUNTSMAN CLINIC CHECK IN TO PROVIDER PAGE PROCESS FISHBONE DIAGRAM
Oncology team: Lindsay Burt, MD; Chris Baker, MD; Chris Weil, MD; Josh Gruhl, MD; Matthew arsons, MD; Ryan Hutten, MD; Ryan Kraus, MD; Timothy Griffith MD
CONCLUSION
Solving the age-old problems of health care doesn鈥檛 require more solutions. It requires better understanding of problems. The oncology residents found the fishbone a useful tool to illustrate how many variables contribute to a seemingly simple question: 鈥渨hy don鈥檛 we get paged sooner?鈥 By breaking the problem into a series of categorized causes, the team identified overlap between workflows. Using this information, the team is now prioritizing causes from high-to-low effort to begin making improvements.
*Originally published Janurary 2021
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CONTRIBUTOR
Luca Boi
Senior Consultant, Process Improvement, Analytics, Planning, Strategy and Improvement, Brigham and Women's Hospital
