[CQI Team Name] Fishbone Diagram



472557848577500Fishbone DiagramA fishbone diagram can be used to conduct a root cause analysis to better understand why a problem occurs. 5047615117008A root cause analysis is the process of identifying the underlying factors that lead to a problem. 020000A root cause analysis is the process of identifying the underlying factors that lead to a problem. It helps teams identify – Underlying or root causes of a problemA target for improvement that is likely to lead to changeGaps in knowledge that require additional data collection or explorationWhen should you use a Fishbone Diagram?Teams should use this tool after a problem has been identified during the planning stage of their PDSA cycle. Taking time to complete a fishbone diagram during the planning stage prevents teams from jumping to a solution before fully understanding the problem.Steps for completing your Fishbone Diagram as a team (see fillable diagram on page 3)Decide on a problem statement (i.e., an area for improvement the team identified). Your problem statement should be specific and reflect an outcome within the team’s control or influence. Write your problem statement in the circle on the far right side of your diagram. Think deeply and broadly about why the problem may be occuring, starting with high level aspects of the program (i.e., major causes). Aspects to consider include, but are not limited to, factors related to your clients/service population, the environment, staffing/staff characteristics, program policies and procedures, and community culture/societal norms. Write the major causes on the ends of each arrow (bone) leading to the backbone of your Fishbone Diagram. Examine each major cause and brainstorm more specifics within that aspect of the program that may be contributing to the problem (i.e., minor causes). The more specific you can be, the better. Write your comprehensive list of minor causes on the smaller lines of the bones. It’s ok if one minor cause occurs on more than one major bone. The minor causes will inform the solution(s) you test in your CQI project(s). Strategies for SuccessFor the most robust root cause analysis, engage a diverse team of brainstormers with various viewpoints of the problem. Find causes that your team can impact. For example, program processes are things the team can impact but attributes of families are not. Know when to stop. You can stop brainstorming once your team has a comprehensive understanding of the problem.Example Fishbone Diagram-952500173990Historical traumaNeed to track and review % of families meeting visit frequency with staffStaff unable to be flexible with their work schedulesInconsistent onboarding proceduresProgram is new/ unknown to communityDistrust of home visitsCaregivers need teasers to get excited about next visit Caregivers lacking support from other family members Program does not offer incentives to participateHard to engage when there are competing prioritiesFamilies do not provide input on visit contentFamilies forget/not tracking when next visit is scheduledHV may not be the best fit for the familyDistance to travel restricts the # of visits that get done Caseloads sometimes too highFamily may not understand the program requirementsCaregiver work schedule conflicts with HVFamilies forget/not tracking when next visit is scheduledCaseloads/staffingFamily engagement strategiesStigma/normsFamily barriersCaregiver motivationProgram policies/ proceduresFamilies are not receiving the # of home visits they should 00Historical traumaNeed to track and review % of families meeting visit frequency with staffStaff unable to be flexible with their work schedulesInconsistent onboarding proceduresProgram is new/ unknown to communityDistrust of home visitsCaregivers need teasers to get excited about next visit Caregivers lacking support from other family members Program does not offer incentives to participateHard to engage when there are competing prioritiesFamilies do not provide input on visit contentFamilies forget/not tracking when next visit is scheduledHV may not be the best fit for the familyDistance to travel restricts the # of visits that get done Caseloads sometimes too highFamily may not understand the program requirementsCaregiver work schedule conflicts with HVFamilies forget/not tracking when next visit is scheduledCaseloads/staffingFamily engagement strategiesStigma/normsFamily barriersCaregiver motivationProgram policies/ proceduresFamilies are not receiving the # of home visits they should 51970797239341. Write your problem statement here001. Write your problem statement here58483501028703212322211299525018044748452. Identify major causes of the problem 002. Identify major causes of the problem 146463821463045795334826029337053486053. Brainstorm minor causes related to each major cause003. Brainstorm minor causes related to each major causeHow to Interpret your Fishbone DiagramOnce you have completed your Fishbone Diagram, take time to interpret it as a team and decide which minor cause your PDSA cycle will focus on. Consider the following: Are there causes that come up repeatedly within your diagram?Which causes are particularly important for the team to focus on? Do any of the causes come as a surprise? Which causes are within the team’s control to influence? These considerations should assist the team in identifying one root cause to address through a PDSA cycle. It may be difficult to identify just one root cause to target, but is important to narrow your scope and address only one at a time. You can always return to your diagram for future PDSA cycles!7153275662235600-247650187960[Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause]Major CauseMajor CauseMajor CauseMajor CauseMajor CauseMajor CauseProblem Statement[Minor Cause][Minor Cause ][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause][Minor Cause]Major CauseMajor CauseMajor CauseMajor CauseMajor CauseMajor CauseProblem Statement[Minor Cause][Minor Cause ][Minor Cause] ................
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