The team decided that
this issue was a priority to address and the Nursing Director took a leadership
role in bringing together the team involved in preparing the pre-op paperwork
to review the problem and propose solutions. The team was able to work together
to quickly make some significant improvements while learning some core concepts
of problem solving. Some of the tools and techniques that the team followed are
summarized below.
1. Identifying the cause(s) of the problem
Problems are just the
negative effects that are caused by failures of a process or system. One great
tool for identifying the causes of a problem is a fishbone diagram (also sometimes
called an Ishikawa or cause-effect diagram). By starting with the problem, or effect,
you work backwards to identify possible causes.
For the problem
"wrong discharge instructions given to the patient" our healthcare
team informally identified several possible causes including:
· The wrong discharge
instructions being pulled from the file
· Misfiling of the
discharge instructions
· The surgeon's orders being
misread or misinterpreted
· An error made in the
patient booking process
· The procedure being changed
after the discharge orders were setup
2. Go to the Gemba
When identifying
causes of a problem don't do it alone and definitely don't just do it in a
meeting room. Remember the concept of the 3 Reals:
"Go to the real place to observe the real thing to get the real facts and data."
The Japanese word
"gemba" translates to "the real place" and is often used as
a reminder of the value in observing the actual process or system. Managers
should make "gemba walks" a regular part of their day. The most
successful problem solvers not only address the problem at the real place they
also address it right after it occurs and before the situation has changed. It
is often easier for an outsider who does not deal with the process every day to
identify causes of the problem.
Our improvement team
was able to see one possible cause of discharge instructions being pulled from
the wrong file only when we went to gemba. Looking at the actual discharge
instruction files it was easy to see that a file folder was mislabeled. The
correction was completed in about a minute.
3. Getting to the root cause(s) of the
problem
When dealing with the
dandelions and other weeds that grow in my yard I have learned that cutting off
the flower or pulling off the leaves is just a short term fix. My lawn may look good for a few weeks, but it
is inevitable that those weeds will grow back and I will need to deal with them
again. Most of our problems and issues
are just like those weeds; if we want to prevent them from coming back we need
to dig deep and get to the root.
Correctly identifying the root cause is the key to effective problem
solving.
Toyota popularized the
method of asking "why?" at least five times. This can be done informally
or formally in a cause-and-effect diagram. For some problems you may get to
root cause in only a few "whys?" while for complex issues you may need
to ask more than five. Keep in mind that 99% of the time the process or system
is at fault, not a person. People do not fail, processes do.
Members of our
healthcare improvement team were able to see that the complexity of the ordering
instruction system was a root cause of many of the issues. Once they arrived at
this root cause it was possible to look at solutions that would combine and
consolidate the paperwork. Part of the solution involved changing the process
to one with only a few variables: inpatient or outpatient, diabetic patient or
not diabetic, etc. Simplifying the
process was also an opportunity for the staff to implement some mistake
proofing, but we will cover this topic in a future post.
Hopefully these three
tips can benefit your team as you tackle challenging problems. Please leave a comment if this information is
helpful.
Steve Musica
Principal, 1group
