LEAN IN HEALTHCARE
Delivering improvement through cause and effect
I
f you are reading this article, it is likely you have been charged with reducing or eliminating an issue within your department. To achieve this, you must first understand clearly what the issue actually is, identify the root causes that drive the issue and then carry out activities to eliminate, reduce or control those causes.
A powerful yet simple, easy- to-use tool to help you and your team do this is the Cause and Effect diagram (C&E), also variously known as a fishbone or Ishikawa diagram. Traditionally, this is carried out as a brown paper exercise along with marker pens, adhesive notes and a can of spray adhesive.
It is also now possible to carry this out electronically with Quality Companion by Minitab®, allowing those taking part to drag and drop and relocate information instantly – with the resulting C&E being very much more portable and simpler to communicate than a roll of paper!
First you need to define the issue. Let us say, for example, that there is a bed blockage issue within your area of responsibility, meaning a patient cannot be admitted and/or may be released prematurely.
This failure to meet patient requirements is your issue or defect (taken from the industrial definition, where C&E originated). This issue forms the ‘head’ of the fish body on the C&E.
Broad, generic main causes are Jul/Aug 10
then placed onto the backbone of the fish and shown as branches. In industry, the ‘6Ms’ (man, machine, method, measurement, material and Mother Nature) are used to identify these causes.
In healthcare, these are more commonly known as the ‘6Ps’ – policies, plans, procedures, people, plant, patients. Working with your team, you should brainstorm what the causes of the issue might be. There are likely to be many of these and it is quite possible several causes may interact.
Don’t discount any ideas and think both broad and deeply about the possible drivers for the problem – to permanently fix the issue, you need to identify the true, root cause(s). Try to think beyond the obvious. If the answer is an easy one, chances are the problem would not exist and you would not be working to address it.
You may find it useful to take each generic main cause in turn, listing the possible sub-causes under each heading though you should not get too hung-up on trying to identify sub-causes for every branch – there may not be one.
You can also get creative here. If you believe you have additional and/or more relevant main causes, do use them.
If necessary, you can add additional ‘flesh’ to the fish – for instance to capture detail it may be useful to have branches from sub-causes or to add pictures, drawings and data.
Your result is a C&E with your issue at the head and an extensive set of the potential causes of that issue, some of which will be the critical driver(s) or root cause(s) of your problem if the team has successfully captured the true variables. It is also a useful tool for communicating your work to those whose process you are studying.
The next step is to work through each potential cause to determine if this is a critical variable or can be eliminated. This could be through data, experimentation, other process- improvement tools or expert
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knowledge which can be useful but can also lead you to exactly where you are now – do challenge it! You may find it helpful to prioritise the order in which you work through the variables, particularly if there is a hunch or some are easier to address than others.
Just make sure you do consider all of the factors identified so no opportunities are missed.
The result ought to be a relatively small, manageable shortlist of truly important factors to be analysed and improved upon by your team.
Many resources are available at
www.QualityCompanion.co.uk to help people who are new to Lean and quality improvement techniques when using Quality Companion by Minitab.
Take a look to find out more or download a free trial and try creating your own Cause and Effect diagram.
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