Losing the blame
with cause-and-effect charts
From the time that Edmund, a character in Shakespeare’s King Lear, noted that we place blame for unacceptable outcomes wherever we can—even in the stars and eclipses— it has appeared to be human nature to focus on blaming, rather than seeking genuine causes. Certainly this can be said in contemporary business and service environments, where the first reaction is to ask "Who's to blame?" rather than "What circumstances caused this to happen?"
Fortunately, cause-and-effect relationships can in fact be teased out of situations, focusing attention on root causes of a problem or unacceptable background and placing "blame" on a system, rather than on individuals within that system.
The Ishikawa diagram, otherwise known as a fishbone or cause-and-effect diagram, is among useful problem-solving tools that are at the disposal of quality professionals and others who want to improve a system and derail unacceptable outcomes. If the office’s morning coffee is cold, for example, you can chew out the caterer; this might make you feel better, but will not solve the problem or assure hot coffee for tomorrow. A more useful approach is to begin to ask the question "Why?" and continue to ask it until the root problem surfaces.
Q. Why is the coffee cold this morning?
A. It was delivered early and sat in the container longer than usual.
Q. Why was it delivered earlier than usual?
A. The coffee caterer had additional orders to be delivered and had to bring ours earlier.
Q. Why did this affect delivery time?
A. No staff has been added to meet needs of expanding customer base.
Q. Why were no additional staff members added?
A. The catering company’s boss wanted to improve the bottom line of profits this month.
Q. Why do they need profits to go up this month?
A. A stockholders’ meeting takes place next month, and the board will demand greater profitability from the catering company.
As this simple example demonstrates, a disappointing outcome probably has nothing to do with the immediate problem, but often goes much further with respect to contributing conditions. (In this case, short-term thinking, that is, the need to respond to an immediate cry for profits rather than considering long-term implications, is really the culprit.)
In order to consider many contributing causes at the same time, brainstorming and then creating a cause-and-effect diagram may eliminate a number of steps in getting to the root cause of a problem.
Considering a problem that is endemic to a hospital environment, let us examine the challenge of delivering medications from the hospital pharmacy in a timely way so patients can begin to benefit from their medications. St. Cured in a Day Hospital was experiencing this problem on a regular basis. After doctors, patients, and nursing staff complained to the pharmacy, the chief customer service administrator formed a team composed of employees with concerns about the issue.
Addressing the question, "What contributes to the late delivery of medications to patients?", the team brainstormed, generating the following list of potential contributors:
- Crowded nursing stations
- New pharmacists on staff
- Interruptions in pharmacy
- Quantity of medication not clear
- Not enough delivery carts
- Medications do not always fit into containers
- Difficulty in reading orders
- Request forms too small
- Staff not familiar with generic names vs. trade names of meds
- Unpredictable times of delivery to stations
- Pharmacy receives too many telephone requests
- Physician revises medication
- Proper size syringes not always available
- Cannot find procedures
- Labels hard to read
- Medication out of stock
- Limited training on new meds
- Incorrect scheduling
- Order delayed
- Physician unavailable to prescribe
- Pharmacist unfamiliar with medication
- Telephoned medication requests
- Workload uneven
- Incorrect scheduling
- Scale (balance) is touchy in pharmacy
- Inventory not organized
Next, the outcome of this brainstorming session was considered with respect to categories: traditionally, these categories represent equipment, measurement, people, environment, material, and information aids.
After the brainstormed items had been entered on the cause-and-effect diagram on the appropriate “bones” of the fishbone, it looked like this:
As the group reviewed the diagram, team members identified those causes that were not necessarily related to the outcome (late medications), and focused only on those that seemed to be likely causes. And finally, after discussion, they decided to focus on the telephoned medication requests as a potential likely cause.
To verify the relationship between telephoned requests and late delivery of medications, the group created a scatter diagram, an informal method of determining whether such a relationship actually exists (see accompanying Quality Quiz for more about scatter diagrams). The scatter diagram suggested that among the medications that were delivered late, most had been ordered by telephone, thus giving the group a data basis for focusing on telephoned medication requests.
After determining the most likely cause for late medications, and verifying the relationship with a scatter diagram, the group had two options:
- place "telephoned medication requests" in the "outcome" box of a new cause-and-effect diagram, and then brainstorm for contributing factors to the telephoned requests. (This is the "Why?" "Why?" "Why?" approach in a visual format.)
- address "telephoned medication requests" as a cause, and pursue improvement efforts to address this area of concern.
These tools provide a focus on the way a system (such as the system of delivery of medications) works. Many times, those who work within a system have little awareness of how it works, beyond their own area, so this is useful in itself. Beyond this understanding, tools help to isolate areas for improvement and address them in a comprehensive way.
Of course, an alternative approach would be just to blame it on the full moon...
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