The first step in making an improvement is to identify where a problem exists, maybe from a clinical audit review, clinical incidents, patient feedback or there is an opportunity to enhance patient care. Involve team members to capture collective knowledge about the problem, ensuring the focus is on root causes, not symptoms.
Here are some tools that can help you to fully understand why a problem has occurred and what might need to be done to remedy it.
Root Cause Analysis
When incidents happen, it is important that lessons are learned to prevent the same incident occurring elsewhere. Root Cause Analysis (RCA) investigation is a well-recognised way of doing this. It is used to identify areas for change and to develop recommendations which deliver safer care for your patients. It seeks to:
- Determine what happened
- Understand why it happened
- How to reduce the likelihood that it will happen again.
The RCA process has five steps:
RCA using ‘five whys’
By asking the question ‘why?’ you can peel away the layers of an issue to get to its root cause. It can uncover the root cause of a problem that has occurred during a project or programme. It not only uncovers glitches in the delivery, but also issues with organisational or team processes.
Reasons for a problem can often lead into another question. You may need to ask why more than five times to get to the origin of a problem. Remember to:
- Avoid assumptions and encourage your team to keep drilling down to the real root cause of a problem
- Focus your resources in the correct areas and make sure the right action is taken
- Ground your answers in fact, avoiding listing events that might have happened.
‘Five whys’ in action – a practical example – missing text?
Root cause – there is no equipment maintenance schedule. Setting up a proper maintenance schedule helps ensure that patients should never again be late due to faulty equipment. This reduces delays and improves flow. If you simply repair the trolley or do a one-off safety rail check, the problem may happen again sometime in the future.
The ‘five whys’ technique uses counter-measures, rather than solutions. This makes sure that action(s) prevent the problem arising again, rather than a solution which just deals with the situation.
RCA using the cause and effect diagram
This tool will help you to spot, sort and display possible causes of a specific problem. The fishbone diagram illustrates the relationship between the outcome and the factors that influence it.
The problem is placed at the head of the fish, then major categories or process steps are placed at the end of the bones. Be flexible with the categories chosen. To identify causes under each category, review existing data and consider, ‘Why is this happening?’
Repeat this approach for each category until you drill down to the root cause.
Force Field Analysis
What is it?
A Force Field Analysis is a quality improvement tool designed to identify driving (positive) and restraining (negative) forces that support or work against the solution of an issue or problem.
When the driving and restraining forces are identified, steps can be taken to reinforce the driving forces and reduce the restraining forces
What does the Force Field do?
- Allows comparisons of the ‘positives’ and ‘negatives’ of a situation
- Enables easy comparisons
- Forces people to think together about all the aspects of making the desired change a permanent one
- Encourages people to agree about the relative priority of factors on each side of an issue
- Supports the honest and open reflection on the underlying root
causes of a problem and ways to break down barriers.
How to create a Force Field Analysis
- Draw a letter ‘T’ on a flip chart page
- Write the name of the issue or project across the top of the page
- Label the left column ‘Driving Forces’ and the right column the ‘Restraining Forces’
- Use brainstorming or nominal group technique (NGT) to generate the list of forces or factors that are driving the issue or project and those that are restraining or the holding things back
- Eliminate duplicate ideas and clarify any ideas that are vague or not specific
- If the team feels the need, they can use rank ordering to set priorities for the driving and restraining forces
- Generate a list of ideas about actions that can be taken to reduce the restraining forces’
Example of a Force Field Analysis
- If you’re not sure the root cause of the problem is correctly identified, use our more in-depth Root Cause Analysis. Download here.
- Read more information about the Cause and Effect Diagram. Download here.
- Watch this short video clip about the Cause and Effect Diagram.
- More information about Force Field analysis
Whiteboard: Force Field analysis
- The Force Field analysis template
- Using Force Field analysis to identify and consider forces that support and hinder change