A prescriber-patient miscommunication causes an adverse drug interaction, the nurse administers the wrong immunization to the patient, or the EMR system goes down five times a day. When adverse events like these occur, it might feel like it’s time for a fishing vacation, but what these events really call for is a root cause analysis (RCA). One simple and effective tool for RCA is the Fishbone Diagram. The Fishbone Diagram is a quality improvement tool used to guide a structured investigation of what went wrong and why, and it helps generate solutions to prevent an event from reoccurring. Think of the fishbone RCA process as casting a wide net and fishing for solutions to problems. While fishing is often a solitary, quiet activity, the Fishbone Diagram process is a group effort. So, share this overview of the Fishbone Diagram and the following case example with your quality improvement team as a way to gear up for your next RCA.
The fishbone diagram is often called the Ishikawa Diagram, as it was created by engineering professor, Kaoru Ishikawa, a leading authority in quality control in the 1960s. Ishikawa created the fishbone diagram process as a technique for visualizing causal connections. The diagram resembles a fish skeleton with the head representing the problematic outcome and each of the bones branching off the fish spine denoting the causal factors that contributed to the problem. Taken together, the fish skeleton presents a visual representation of the causes (fish bones) that led to the effect (fish head). See figure below.
The first step in the fishbone exercise is to articulate the process as a collective, open brainstorming session that invites input from all members of the team. The goal is to find and resolve weaknesses in the system, not blame any one individual or subgroup. The old adage, often attributed to Deming, ‘every system is perfectly designed to get the results it gets,’ is a great way to set up the fishbone analysis. This openness also can be achieved through the use of poster board, on which to draw the fishbone, and sticky-notes, to allow brainstorming to occur both verbally and in writing.
Once the fishbone process is explained and the fish skeleton graphic is displayed on poster board, the second step is to, as a group, describe the problem. Spend as much time as needed to develop consensus around a clear, concise, factual description of the issue. Write down the problem statement at the head of the fish (e.g., medication error – improper dosing).
The third step is to label each bone branching off the fish spine with the categories of causes which contributed to the problem. The standard fishbone causal categories are Machine, Materials, Methods, People, and Environment. However, in a healthcare context, these six P’s offer more useful categories: Polices, Procedures, Programs (EMR), Patients (clients), Providers (staff), and Place (environment).
In the fourth step of the process, the group brainstorms the sub-causes that contributed to the problem under each of the six categories. This can be done in groups of six, with a report back to the larger group, or can be done one category at a time by the entire group. Here again, the idea is to use brainstorming techniques to break down a multidimensional problem into its elemental, root causes. It is a time to methodically look back and analyze causes, not suggest solutions. This step is often aided by the use of the 5 whys technique. In this iterative approach, the facilitator asks a series of 5 ‘why’ questions, each one building upon the previous answer to drill down into the fundamental issue. For example, in the category of Programs (EMR) the 5 whys technique might look like this:
Q: Why did the EMR system go down? A: The server crashed.
Q: Why did the server crash? A: There was not enough space in virtual memory.
Q: Why was there not enough memory? A: Scanned images are taking up too much memory.
Q: Why are image files too large? A: They are set at maximum resolution
Q Why do they need to be set at maximum resolution? A: They don’t, they are legible at half the resolution.
Once all the potential root causes have been listed under each causal category, the final step is to have the team identify the themes that emerged in the process and begin to suggest solutions that can help prevent the problem from reoccurring. This could be any combination of changes to policy, procedures, modifications to the physical environment, training for providers, or different ways to engage with the patient’s family members. The fishbone process could also prompt the use of other quality improvement approaches such as a Plan, Do, Study, Act (PDSA) cycle to test out a potential solution. Alternatively, the process might create the need for further data collection, or a more in-depth quality improvement study, to validate subjective hypotheses that emerged during the fishbone process.
To summarize, the five main steps of the fishbone RCA process are: (1) establish an open brainstorming process about system level causes to an adverse event, (2) describe the problem, (3) categorize the potential causes, (4) pinpoint likely root causes in each category, and (5) identify solutions that will mitigate the root causes and prevent the problem from reoccurring.
I once had the opportunity to use the fishbone exercise with an integrated care team to address an issue where significant aspect of patient’s history was not fully shared across the team. The clinic received an ER report of an accidental prescription drug overdose. The report was reviewed in primary care and scanned to a patient’s EMR without being circulated to the specialty mental health providers involved in the patient’s treatment. The ER report was in the patient’s shared EMR for months, while treatment was ongoing, before it was discovered by a mental health provider. Fortunately, the lack of information access did not lead to an adverse outcome for the patient. Nevertheless, our quality improvement team felt the oversight needed to be addressed.
We employed the fishbone diagram process described above and came up with concrete resolutions to this communication issue. In brief, we changed our written policy and procedures on how external reports are processed upon receipt and instituted a new way to use the EMR to alert providers to newly scanned reports. While this was a positive resolution to the issue, we experienced additional secondary effects at the individual and team levels. The collective fishbone process served to strengthen a culture of whole health and interdisciplinary teamwork among the staff. For example, as a result of conducting the fishbone diagram exercise:
- Individuals realized the importance of reviewing all aspects of the patient’s chart regularly.
- Staff members were able to visualize how all different parts of the care team contributed to a single problematic outcome.
- The interconnectedness of treatment planning was underscored.
- We developed an appreciation of the EMR as an enabler of collaborative care.
- The interdisciplinary team united around solving a system level issue.
These team level side-effects of the fishbone diagram root cause analysis process highlight the benefits of conducting this exercise with integrated care teams. Done well, this fishing expedition can, not only solve a problem, but also strengthen the provision of integrated, holistic care.
Adapted from University of North Carolina School of Medicine, Department of Pediatrics https://www.med.unc.edu/pediatrics/quality/files/qi-forms/editable-fishbone-diagram/view
Agency for Healthcare Research and Quality. Cause-and-Effect Diagram. (n.d.). Retrieved May 21, 2018, from https://healthit.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/cause-and-effect-diagram
American Society for Quality. Cause analysis tools: fishbone diagram. (n.d.). Retrieved May 21, 2018, Available from: http://www.asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html
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Kevin Readdean, MSEd, LMHC, is Associate Director of the integrated student health and counseling services at Rensselaer Polytechnic Institute. He is also a PhD student at Rutgers University studying the organization and delivery of integrated primary care behavioral health.