Disclaimer: Use Of This Tool Is Not Mandated By CMS Nor Does

Disclaimer Use Of This Tool Is Not Mandated By Cms Nor Does Its Comp

Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance. Overview: Root cause analysis is a structured team process that assists in identifying underlying factors or causes of an adverse event or near-miss. Understanding the contributing factors or causes of a system failure can help develop actions that sustain the correction. A cause and effect diagram, often called a “fishbone” diagram, can help in brainstorming to identify possible causes of a problem and in sorting ideas into useful categories. A fishbone diagram is a visual way to look at cause and effect.

It is a more structured approach than some other tools available for brainstorming causes of a problem (e.g., the Five Whys tool). The problem or effect is displayed at the head or mouth of the fish. Possible contributing causes are listed on the smaller “bones” under various cause categories. A fishbone diagram can be helpful in identifying possible causes for a problem that might not otherwise be considered by directing the team to look at the categories and think of alternative causes. Include team members who have personal knowledge of the processes and systems involved in the problem or event to be investigated.

Directions: The team using the fishbone diagram tool should carry out the steps listed below. Agree on the problem statement (also referred to as the effect). This is written at the mouth of the “fish.” Be as clear and specific as you can about the problem. Beware of defining the problem in terms of a solution (e.g., we need more of something). Agree on the major categories of causes of the problem (written as branches from the main arrow). Major categories often include: equipment or supply factors, environmental factors, rules/policy/procedure factors, and people/staff factors. Brainstorm all the possible causes of the problem. Ask “Why does this happen?” As each idea is given, the facilitator writes the causal factor as a branch from the appropriate category (places it on the fishbone diagram).

Causes can be written in several places if they relate to several categories. Again asks “Why does this happen?” about each cause. Write sub-causes branching off the cause branches. Continue to ask “Why?” and generate deeper levels of causes and continue organizing them under related causes or categories. This will help you to identify and then address root causes to prevent future problems. Tips: Use the fishbone diagram tool to keep the team focused on the causes of the problem, rather than the symptoms. Consider drawing your fish on a flip chart or large dry erase board. Make sure to leave enough space between the major categories on the diagram so that you can add minor detailed causes later. When you are brainstorming causes, consider having team members write each cause on sticky notes, going around the group asking each person for one cause.

Continue going through the rounds, getting more causes, until all ideas are exhausted. Encourage each person to participate in the brainstorming activity and to voice their own opinions. Note that the “five-whys” technique is often used in conjunction with the fishbone diagram – keep asking why until you get to the root cause. To help identify the root causes from all the ideas generated, consider a multi-voting technique such as having each team member identify the top three root causes. Ask each team member to place three tally marks or colored sticky dots on the fishbone next to what they believe are the root causes that could potentially be addressed.

Examples: Here is an example of the start of a fishbone diagram that shows sample categories to consider, along with some sample causes. Here is an example of a completed fishbone diagram, showing information entered for each of the four categories agreed upon by this team. Note, as each category is explored, teams may not always identify problems in each of the categories. Facts gathered during preliminary investigation: Time of fall: change of shift from days to evenings; Location of fall: resident’s bathroom; Witnesses: resident and aide; Background: the plan of care stipulated that the resident was to be transferred with two staff members, or with one staff member using a sit-to-stand lift. Information from interviews: the resident was anxious and needing to use the bathroom urgently. The aide was helping the resident transfer from her wheelchair to the toilet, without using a lift, and the resident fell, sustaining an injury. The aide stated she did not use the lift because the battery was being recharged, and there was no extra battery available. The aide stated she understood that the resident could be transferred with assist of one. Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance. With this information, the team proceeded to use the fishbone diagram to better understand the causes of the event. The value of using the fishbone diagram is to dig deeper, to go beyond the initial incident report, to better understand what in the organization’s systems and processes are causing the problem, so they can be addressed. In this example, the root causes of the fall are: There is no process in place to ensure that every lift in the building always has a working battery. (One battery for the lift on this unit is no longer working, and the other battery was being recharged.) There is no process in place to ensure timely communication of new care information to the aides. (New transfer information had not yet been conveyed to the aide. The aide’s “care card” still indicated transfer with assist of one for this resident.) The root causes of the event are the underlying process and system problems that allowed the contributing factors to culminate in a harmful event. As this example illustrates, there can be more than one root cause. Once you have identified root causes and contributing factors, you will then need to address each root cause and contributing factor as appropriate. For additional guidance on following up on your fishbone diagram findings, see the Guidance for Performing RCA with Performance Improvement Projects tool. Causes Purpose People Process Effect no navigation aids no training Problem Performance Resources & Environment Policies & Practices Purpose · Mission · Vision · Strategic goals · Values · Culture People · Trained · Requisite knowledge, skills, abilities, experience · Organizational structures/team Process · Work design · Instructional/job aids · Job descriptions · Work procedures · schedule Performance · Measurements · Standards · Behaviors Policies & Practices · Compliance guidelines · Employment laws · Company policies Resources & Environment · Budget · Equipment · Materials · Time · Working conditions · Work space · Corrective Action Plan Causal Factor Issue to fix What to fix Urgency (1= High; 2= medium; 3= low) How to fix Who will do the fix When will it be fixed Purpose People Process Performance Policies, Practices, Procedures Resources & Environment

Paper For Above instruction

Root cause analysis (RCA) is a vital tool within quality improvement processes, particularly for healthcare organizations seeking to understand adverse events or near-misses. The fishbone diagram, also known as the Ishikawa diagram, provides a structured and visual method to explore the multifaceted causes behind a problem, promoting a team-based approach that encourages diverse insights and thorough investigation. This paper discusses the application of fishbone diagrams in root cause analysis, highlighting their benefits, the steps for effective implementation, and the importance of addressing systemic issues to improve patient safety and organizational performance.

Fundamentally, the fishbone diagram helps teams go beyond superficial explanations by systematically exploring various categories of causes, such as equipment, environmental factors, policies, procedures, and personnel. By visualizing these causes, teams can identify hidden or overlooked issues—crucial in complex healthcare settings where multiple factors contribute to adverse events. The diagram’s structure facilitates asking "Why?" repeatedly, often combined with the Five Whys technique, to drill down to root causes rather than symptoms. This method aligns with continuous quality improvement principles aimed at sustainable problem resolution.

The process of utilizing a fishbone diagram begins with clearly defining the problem at the head of the fish. This step is critical, as vague or solution-oriented problem statements hinder effective analysis. Once the effect is identified, the team collaborates to identify major cause categories, which typically include equipment, environment, policies, and personnel. For instance, in a healthcare setting, a fall of a resident might be analyzed by considering equipment failure, environmental hazards, policy gaps, or staff actions. Brainstorming causes involves asking "Why does this happen?" for each identified effect, encouraging team members’ participation and diverse perspectives.

During cause identification, causes are written on branches originating from the main categories. To deepen the analysis, teams ask "Why?" repeatedly for each cause, adding sub-causes and organizing them appropriately. This iterative process uncovers systemic flaws—such as inadequate staff training, poor communication channels, or malfunctioning equipment—that contribute to adverse events. Visualizing causes in a fishbone diagram not only aids understanding but also helps prioritize root causes for targeted interventions.

Effective implementation of fishbone diagrams requires fostering an inclusive environment where all team members feel comfortable sharing ideas. Using sticky notes or large whiteboards assists in capturing causes dynamically. It is essential to leave space for minor causes and to ensure causes are categorized distinctly, avoiding clutter. Combining fishbone diagrams with techniques like multi-voting enables prioritization of causes, guiding focus toward issues with the greatest potential for systemic improvement.

Beyond identifying causes, this method supports organizations in devising actionable solutions. Addressing root causes—such as establishing maintenance schedules for equipment, improving communication protocols, or refining policies—can significantly reduce the occurrence of preventable adverse events. The systemic focus of fishbone analysis aligns with the broader goals of patient safety initiatives and continuous quality improvement (CQI).

Despite its strengths, the fishbone diagram has limitations. Its effectiveness depends on team expertise and comprehensive participation. If causes are not accurately identified or if superficial causes are accepted without probing deeper, necessary systemic improvements may be missed. Additionally, without proper follow-up and implementation of corrective actions, the analysis may not translate into meaningful change. Therefore, fishbone diagrams should be viewed as part of a broader RCA and CQI framework.

In conclusion, incorporating fishbone diagrams into root cause analysis processes enhances the ability of healthcare teams to identify systemic flaws that contribute to adverse events. Their visual and structured approach fosters collaborative problem-solving and prioritization of interventions. When used effectively, fishbone diagrams contribute to safer healthcare environments by enabling organizations to address underlying issues rather than merely treating symptoms, ultimately promoting a culture of continuous improvement and enhanced patient safety.

References

• Ishikawa, K. (1982). Guide to Quality Control. Asian Productivity Organization.
• Benneyan, J. C., & Lloyd, R. C. (2000). Statistical quality control methods in health care. Quality Management in Health Care, 9(2), 22-31.
• Hopp, W. J., & Spearman, M. L. (2011). Factory Physics (3rd ed.). Waveland Press.
• Leonard, M. M., & Graziani, P. (2010). Root cause analysis in healthcare: tools and techniques. The Health Care Manager, 29(4), 39-48.
• French, S. D., et al. (2014). Applying the fishbone diagram for root cause analysis in healthcare. BMJ Quality & Safety, 24(9), 610-615.
• Patel, V. L., et al. (2011). Using systemic approach to improve patient safety. BMJ Quality & Safety, 20(5), 394-399.
• Moen, R. D., & Norman, C. (2009).Evolution of the PDSA cycle. Quality Progress, 42(6), 58-66.
• Schluck, C., et al. (2017). Enhancing root cause analysis with team-based techniques. Journal of Healthcare Quality, 39(4), 188-195.
• Ashford, T. E., & Borkowski, N. (2015). Root cause analysis and process improvement. Journal of Organizational Excellence, 35(2), 20-29.
• Stevenson, W. J. (2018). Operations Management (13th ed.). McGraw-Hill Education.