Vol. 11, No. 3

March 2009

PQ Systems
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Quality Quiz from Professor Cleary

"A" is correct.

Click here for a more complete video explanation

Doug’s curiosity about the causes of so many late prescriptions leads him to consult Practical Tools for Healthcare Quality (Sandra and O. Byron Murray), where he finds information about using cause-and-effect diagrams, or Ishikawa charts, to analyze causes. This is the first tool that he should use, although further analysis may be supported by other problem-solving tools. A cause-and-effect diagram will get to the causes of the problem of late medications.

A cause-and-effect (C&E) diagram is, after all, a picture of elements that contribute to a particular problem or outcome. “Aha!” Doug Dren says to himself. “This is exactly what I need to sort out the causes of late medications from the pharmacy.”

According to the text that he found himself reading late at night (since he couldn’t sleep anyway), cause-and-effect diagrams are used to find special or common causes of variation and to analyze causes. The book indicated that the time to use a C&E diagram is when one can answer one or both of the following questions:

  • Do root causes of a problem need to be identified?
  • Are there ideas and/or opinions about the causes of the problem?

There were certainly lots of opinions at St. Gesundheit about causes, Doug Dren thought ruefully. Most of them placed blame with him, as the new pharmacist. He knew that the issue was more complex than that, so a C&E diagram might actually help.

Doug Dren drew and labeled the main “bones” of the diagram, with major lines categorized according to materials, people, method, and machine. Those labels would work for the hospital, though he knew they could be customized for a better fit, so he added another: “Information aids.”

The first step in using a C&E diagram, Doug Dren noted in the Practical Tools chapter was to identify the problem, also known as the effect. “Well, duh,” Doug thought to himself, recognizing that he would probably not be reading this chapter if it had not been for the late medications problem. Nonetheless, he composed a “problem statement”—“Late medications”—and labeled the main bones of the diagram.

The following day, Doug Dren took his chart skeleton to the hospital, where he assembled a team of those involved in the medication delivery process throughout the hospital and asked them to brainstorm all possible causes of late medications, reminding them not to evaluate each other’s suggestions, and to take turns contributing ideas. Right away, when Ima Farma said “we need new equipment,” Doug had to ask the team to recall that their ideas shouldn’t imply solutions. “Oh, all right,” Ida said, changing her contribution to “carts broken.”

Once the brainstorming was complete, the suggested causes were placed on the fishbone chart. As they were entered, those ideas that seemed the least likely causes were eliminated, and the most likely causes were circled.

The next step would be to collect data in order to analyze these causes and to examine their relationship to the problem (effect). Some of the suggested causes may have been problems in themselves (Aha! Another C&E diagram!), but did not contribute directly to the problem of late medications. For example, “no regular training for new medications” is an area that should undoubtedly be addressed, but does not necessarily contribute to the problem being examined.

After collecting data and consulting with his team, Doug Dren realized that the greatest contributor to late medications seemed to be that so many requests for medications were phoned to the pharmacy. A scatter diagram helped him and his team see the relationship between these phoned-in medications and late deliveries of medications to patients.

Understanding what contributes to a problem is only the first step in solving that problem, of course. But this understanding helps to focus thinking and open the door to data collection that will verify or discount ideas that are presented. Once causes for a problem have been identified, other tools will help to address these causes and ultimately get to the heart of the problem.

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