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Tools for Identifying Causes and Developing Goals in the PDSA Plan Step
- 1. PDSA – tools used in ‘Plan’ Jess Morritt
- 2. PDSA Cycle
- 3. Step 1: Plan Plan the test or observation, including a plan for collecting data: State the objective of the test Make predictions about what will happen and why Develop a plan to test the change
- 4. Tools to help define the problem.
- 5. Root Cause Analysis Provides a retrospective review of an incident or event to identify: What happened? How it happened? Why it happened? How solutions can be developed and fed back.
- 6. The following tools can be used to identify the cause of the issue… 5 why’s Brainstorming Fishbone
- 7. 5 Whys Simple problem solving technique Looks at any problem and asks, why? Answer the the first why often prompts another why Quickly determines root causes Easy to learn and apply
- 8. 5 Whys Example The problem: Patient X is unhappy with treatment by nursing staff Why is our patient unhappy? Why were we unable to meet the agreed-upon timeline for delivery? Why did it take so much longer? Why did we underestimate the complexity of the job? Why didn’t we do this?
- 9. Brainstorming Technique used to generate large quantities of ideas Formal or informal brainstorming
- 10. Fishbone Diagram Fishbone diagrams are used to identify possible causes of problems. A more structured form of brainstorming
- 12. Tools to help develop goals to test change S Specific M Measurable A Attainable R Relevant T Time-bound
- 13. Our brainstorm plan to choose PPE
Editor's Notes
- The Scottish Government. (2010). Retrieved January 9, 2012, from http://www.scotland.gov.uk/Publications/2010/05/27100542/1
- Plan the test or observation, including a plan for collecting data:State the objective of the testMake predictions about what will happen and whyDevelop a plan to test the change (Who? What? When? Where? What data need to be collected?)Science of Improvement: Testing Changes. (2011). Retrieved January 9, 2012, from http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx
- Can be used in the plan stage, and also in the Act stage, so just briefly…Provides a retrospective review of an incident or event to identify:What happened?How it happened?Why it happened?How solutions can be developed and fed back.Root Cause Analysis. (2007). Retrieved January 9, 2012, from http://www.clinicalgovernance.scot.nhs.uk/section2/analysis.asp
- The 3 tools I will be focusing on…Image sourced from:http://files.sharenator.com/QuestionMark_Piss_Off-s350x350-226998.gifhttp://www.theartsnob.com/images/gallery-2003/brain-storm.jpghttp://operachic.typepad.com/photos/uncategorized/2008/01/31/fishbone.jpg
- The 5 Whys is a simple problem-solving technique that helps you to get to the root of a problem quickly. The 5 Whys strategy involves looking at any problem and asking: "Why?" and "What caused this problem?”Very often, the answer to the first "why" will prompt another "why" and the answer to the second "why" will prompt another and so on; hence the name the 5 Whys strategy.Benefits of the 5 Whys include:It helps you to quickly determine the root cause of a problem.It's simple, and easy to learn and apply.5 Whys: Quickly Getting to the Root of a Problem. (2012). Retrieved January 9, 2012, from http://www.mindtools.com/pages/article/newTMC_5W.htm
- In this example, the problem is that your Client X., is unhappy with treatment by nursing staffUsing the 5 Whys, you go through the following steps to get to the cause of the problem:Why is our patient, unhappy? Because we didn't deliver our services when we said we would.Why were we unable to meet the agreed-upon timeline for delivery? The job took much longer than we thought it would.Why did it take so much longer? Because we underestimated the complexity of the job.Why did we underestimate the complexity of the job? Because we made a quick estimate of the time needed to complete it, and didn't list the individual stages needed to complete the job.Why didn't we do this? Because we were running behind with other patients. We clearly need to review our time estimation and specification procedures.Example adapted from:5 Whys: Quickly Getting to the Root of a Problem. (2012). Retrieved January 9, 2012, from http://www.mindtools.com/pages/article/newTMC_5W.htm
- Brainstorming is a technique used to generate large quantities of ideas from a group of people. It is often used in identifying possible causes of an effect or possible solutions.Brainstorming is underpinned by the following principles:People must feel safe to join inNo judgment is allowed during brainstormingPeople should strive to generate as many ideas as possiblePeople should be encouraged to be as creative as possiblePeople should be encouraged to build on each others ideasPerson recording writes down exactly what is saidFormal brainstorming involves going around the group recording one idea at a time. This can be slow and may lack spontaneity. Informal brainstorming involves people shouting out idea as soon as they think of them. It is very spontaneous, but there is a risk that the more outspoken may dominate. Silent methods can be used in which everyone initially records there own ideas. This ensures greater involvement but may not allow development of ideas. Tool 4: Brainstorming. (2003). Retrieved January 9, 2012, from http://www.natpact.info/demand_management/wizards/big_wizard/index.php?page=/demand_management/wizards/big_wizard/Toolkit/Tool_7__Fishbone_Diagram.php
- Fishbone diagrams are used to identify possible causes of problems.MethodDefine the problem to be investigated, and write this in a text box at the right hand side of the pageDraw a fishbone structure with a horizontal line across the page to the text box, and three or four diagonal lines radiating off from the horizontal both above and below it (these are the bones)Brainstorm (Tool 4) on to post-it notes all possible causes of the problem.Consider the first cause and place it on to one of the bones. Consider the second cause. If it is similar to the first place it on the same bone, if not place it on a separate bone.Continue until all post-it notes have been used, adding extra bones as required. Sometimes a single cause could be place upon several bones. In this situation place it on the bone that the majority of the group are comfortable with.Finally review the bones and decide upon labels for them. Tool 7: Fishbone Diagram. (2003). Retrieved January 9, 2012, from http://www.natpact.info/demand_management/wizards/big_wizard/index.php?page=/demand_management/wizards/big_wizard/Toolkit/Tool_7__Fishbone_Diagram.php
- Diagram used at the San Carlos Hospital.Problem: Pregnant women anticipating delivery are not motivted to decide if their partner or family member should accompany them during the delivery.PersonnelDoes not speak with clients about this topicClientsNo opportunity to decideMany come aloneLack informationEnvironmentInadequate infrastructureDelivery room connected to quarantine areaInputsLack delivery room clothing for partner or familyUSAID from the American People (n.d.). Cause-and-Effect Analysis. Retrieved January 9, 2012, from http://www.hciproject.org/improvement_tools/improvement_methods/analytical_tools/cause_effect_analysis
- A useful way of making goals more powerful is to use the SMART mnemonic. Personal Goal Setting. (2012). Retrieved January 9, 2012, from http://www.mindtools.com/page6.html
- This is the brainstorm that our group created while in the planning stages to select a topic, which ended up being Personal Protective Equipment compliance.Infection Control. (2012). Retrieved January 9, 2012, from https://www.mindmeister.com/130820868