QI Tool: The Fishbone Diagram

EIS Quality Learning Network May 10, 2010

Quality Improvement Tools

What tools can help my HIV care program analyze information and make decisions?

Organizing “Theories of Cause”

Process problems are often caused by:

• Methods • Materials• Equipment• Environment• People

Fishbone Diagram

• Organizes and displays all causes and sub-causes that may influence a problem, outcome, or effect

• Helps push people to think beyond the obvious causes, (money, time) to find some causes that they can fix/improve

• Helps organize potential solutions and make clear who should be involved in solutions

• Encourages a balanced view• Demonstrates complexity of the problem

Common Categories

• People: Anyone involved with the process • Methods: How the process is performed and the specific

requirements for doing it, such as systems, policies, procedures, rules and regulations

• Measurements: Data generated from the process that are used to evaluate its quality

• Equipment: computers, tools etc. required to accomplish the job

• Materials: Raw materials, parts, pens, paper, etc. used to produce the final product

• Environment: The conditions, such as location, time, temperature, and culture in which the process operates

Creating a Fishbone Diagram

Low show ratefor appointments

Procedures People

Patients

Patient unawareof appointment

Computer

System downfor routinemaintenance

Skeleton

Equipment Environment

Example: Low Show-Rate for Medical Appts.

Example: Delayed Test Results

Fishbone Diagram: Practice(20 Minutes)

Practice Problem: Low return for confirmatory tests

Please select a facilitator/recorder & report back to full group

1. Write down the problem (fish head)

2. Decide on categories and draw skeleton (e.g., Environment, People, Equipment, Materials, Procedures, Policies, Measurements)

3. Brainstorm as many possible causes as you can and fill in the diagram

4. Ask “why does this happen?” 3 to 5 times

5. Check for logic, completeness and balance

Have the Diagram, Now What?

Need to test the theories

On to your quality improvement work!

Resources• NQC Quality Academy On-line Training, Module 14: Useful QI Tools

NationalQualityCenter.org/QualityAcademy

• American Society for Quality (ASQ) www.asq.org/learn-about-quality/causeanalysistools/overview/fishbone.html

• Ishikawa, Kaoru Introduction to Quality Control (Translator: J. H. Loftus) 1990

• Nancy R. Tague The Quality Toolbox, American Society for Quality 2005