5 Whys Worksheet - HSAG
5 Whys Worksheet
Identify the root cause of your initial problem by completing this worksheet. Start by writing the specific problem. Then, ask why the problem occurs and record the answer. If the answer does not directly identify the root cause of your initial problem, ask why again, and record the answer. Continue this process until the team agrees the problem's root cause has been identified. This process is often complete within five cycles, but can take more or less, depending on the problem.
Example: Q: Why are so many Medicare beneficiaries with heart failure being readmitted to the hospital? A: Because they do not understand or remember the red flags related to their condition after discharge.
Q: Why do they not understand the red flags? A. They do not have the correct documentation or reminder systems in place.
Q: Why do they not have the proper documentation or reminders? A. Because they did not receive a Personal Health Record (PHR) or red flag magnet with documentation of
these red flags upon discharge.
Q. Why did they not receive the PHR or magnet? A. Distribution of these materials is not part of the current discharge process.
By asking a sequence of whys, one can deduce the root cause of a heart failure patient being readmitted to not having a process in place at discharge to educate them on red flags for their specific condition.
Define the problem:
Why is it happening?
1.
Why is that?
2. 3.
Why is that? Why is that?
4.
Why is that?
5.
Example adapted from Care Transitions QIOSC Toolkit, caretransitions/. July 2011 RARE Campaign
This material was adapted by Health Services Advisory Group, the Medicare Quality Improvement Organization (QIO) for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, from material originally prepared by the RARE Campaign. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-C.3-09112017-05
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