Instructions  

Identify a TJC safety goal that is relevant to an area of concern at your place of employment or clinical rotation. Describe a situation in the workplace or nursing practice that needs change.  Then, following the instructions and using the fishbone diagram template found in course documents, complete a Root Cause Analysis of your identified problem.  Attach your fishbone diagram to your discussion board post.

The root cause analysis allows improvement teams to identify the “root” of the problem, where and why the problem exists.  Improvement teams make decisions based on data rather than “hunches” and look for lasting solutions rather than relying on “quick fixes” and “band-aid” approaches. 

  1. Identify a problem
  2. Consider all factors of the problem, such as, “we do not perform adequate pain assessments because…” 
  3. Once all factors causing the problem are identified, it should be evaluated and grouped in categories
  4. Then a “cause and effect” diagram, such as fishbone diagram, can be created. 
  5. General categories may include Environment, Equipment, People, Methods (process) and Materials
  6. Attach your fishbone diagram to your discussion board post

Using the template found in “resources” tab, complete a fishbone diagram of your identified problem. See fishbone diagram document attached.

The cause and effect diagram (fishbone) starts with a problem at the head of the fish.  Under each general category of the fishbone, answer the questions, “Why?” in regard to the problem identified.  Once the fishbone diagram is done, the various causes are discussed to determine the root of the problem.  The results of this discussion drive the focus for the improvement plan.  There may be several causes of the problem.  The team should prioritize which one cause, if solved, would have the most positive impact on the largest number of residents. 

Also, see some useful document attached below.

Instructions

Identify a TJC safety goal that is relevant to an area of concern at your place of employment or clinical rotation. Describe a situation in the workplace or nursing practice that needs change.  Then, following the instructions and using the fishbone diagram template found in course documents, complete a Root Cause Analysis of your identified problem.  Attach your fishbone diagram to your discussion board post.

The root cause analysis allows improvement teams to identify the “root” of the problem, where and why the problem exists.  Improvement teams make decisions based on data rather than “hunches” and look for lasting solutions rather than relying on “quick fixes” and “band-aid” approaches. 

1. Identify a problem

2. Consider all factors of the problem, such as, “we do not perform adequate pain assessments because…” 

3. Once all factors causing the problem are identified, it should be evaluated and grouped in categories

4. Then a “cause and effect” diagram, such as fishbone diagram, can be created. 

5. General categories may include Environment, Equipment, People, Methods (process) and Materials

6. Attach your fishbone diagram to your discussion board post

Using the template found in “resources” tab, complete a fishbone diagram of your identified problem. See fishbone diagram document attached.

The cause and effect diagram (fishbone) starts with a problem at the head of the fish.  Under each general category of the fishbone, answer the questions, “Why?” in regard to the problem identified.  Once the fishbone diagram is done, the various causes are discussed to determine the root of the problem.  The results of this discussion drive the focus for the improvement plan.  There may be several causes of the problem.  The team should prioritize which one cause, if solved, would have the most positive impact on the largest number of residents. 

Safety Discussion Board with Root Cause Analysis Rubric

Criteria

Exemplary

Accomplished

Developing

Beginning

Total

TJC safety goal relevant to an area of concern at your place of employment or clinical rotation is identified.

41-45 points

36-40 points

31-35 points

< 30 points

/45

The safety goal is clearly identified, focused, and relevant to the clinical/work setting described.

The safety goal is identified and is relevant to the clinical/work setting described.

The safety goal is unclear and is somewhat relevant to the clinical/work setting described.

The safety goal is
weak or absent or lacks relevance
to the clinical/work setting described.

Complete a Root Cause Analysis (RCA) of your identified problem.  Attach your fishbone diagram to your discussion board post.

41-45 points

36-40 points

31-35 points

< 30 points

/45

The RCA of the identified problem is comprehensive, focused, and demonstrates a clear understanding of the problem to be addressed.

RCA is included as an attachment to post.

The RCA of the identified problem is focused and demonstrates an adequate understanding of the problem to be addressed. RCA is included as an attachment to post.

The RCA of the identified problem is unclear or narrowly focused but demonstrates awareness of the problem to be addressed.

RCA is included as an attachment to post.

The RCA of the identified problem is weak, absent, or unfocused. Demonstrates minimal understanding of the problem to be addressed.



RCA may or may not be included as an attachment
.



<

Title:

Category

Category

Category

Category

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

Effect

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

cause

Category

Category

Category

Category

Author, Page Number, Date

Copyright © 2004 Institute for Healthcare Improvement

Process Analysis Tools

1

Institute for Healthcare Improvement
Boston, Massachusetts, USA

Cause and Effect Diagram
A cause and effect diagram, also known as an Ishikawa or “fishbone” diagram,

is a graphic tool used to explore and display the possible causes of a certain

effect. Use the classic fishbone diagram when causes group naturally under

the categories of Materials, Methods, Equipment, Environment, and People.

Use a process-type cause and effect diagram to show causes of problems at

each step in the process.

A cause and effect diagram has a variety of benefits:

It helps teams understand that there are many causes that contribute to an
effect.

It graphically displays the relationship of the causes to the effect and to each
other.

It helps to identify areas for improvement.

This tool contains:

Directions for making a Cause and Effect Diagram

Cause and Effect Diagram: “Fishbone”

Cause and Effect Diagram: Process-Type

Copyright © 2004 Institute for Healthcare Improvement

2

Cause and Effect Diagram

Directions

1. Write the effect in a box on the right-hand side of the page.

2. Draw a horizontal line to the left of the effect.

3. Decide on the categories of causes for the effect. Useful categories of causes in a classic
fishbone diagram include Materials, Methods, Equipment, Environment, and People.
Another way to think of categories is in terms of causes at each major step in the process.

4. Draw diagonal lines above and below the horizontal line (these are the “fishbones”), and
label with the categories you have chosen.

5. Generate a list of causes for each category.

6. List the causes on each fishbone, drawing branch bones to show relationships among the
causes.

7. Develop the causes by asking “Why?” until you have reached a useful level of detail—that
is, when the cause is specific enough to be able to test a change and measure its effects.

Copyright © 2004 Institute for Healthcare Improvement

3

Cause and Effect Diagram

Cause and Effect Diagram: “Fishbone”

Copyright © 2004 Institute for Healthcare Improvement

4

Cause and Effect Diagram

Cause and Effect Diagram: Process-Type

Quality and safety education for nurses

Linda Cronenwett, PhD, RN, FAAN
Gwen Sherwood, PhD, RN, FAAN
Jane Barnsteiner, PhD, RN, FAAN
Joanne Disch, PhD, RN, FAAN
Jean Johnson, PhD, RN-C, FAAN
Pamela Mitchell, PhD, CNRN, FAAN
Dori Taylor Sullivan, PhD, RN, CNA, CPHQ

Judith Warren, PhD, RN, BC, FAAN, FACMI

Quality and Safety Education for Nurses (QSEN) ad-
dresses the challenge of preparing nurses with the
competencies necessary to continuously improve
the quality and safety of the health care systems in
which they work. The QSEN faculty members
adapted the Institute of Medicine1 competencies for
nursing (patient-centered care, teamwork and col-
laboration, evidence-based practice, quality im-
provement, safety, and informatics), proposing defi-
nitions that could describe essential features of what it
means to be a competent and respected nurse. Using
the competency definitions, the authors propose
statements of the knowledge, skills, and attitudes
(KSAs) for each competency that should be devel-
oped during pre-licensure nursing education. Quality
and Safety Education for Nurses (QSEN) faculty and
advisory board members invite the profession to com-
ment on the competencies and their definitions and

Linda Cronenwett is a Professor and Dean at the School of Nursing,
University of North Carolina at Chapel Hill.
Gwen Sherwood is a Professor and Associate Dean for Academic
Affairs at the School of Nursing, University of North Carolina at Chapel
Hill.
Jane Barnsteiner is a Professor and Director of Translational Research
at the School of Nursing and Hospital of the University of Pennysylvania,
Philadelphia, PA.
Joanne Disch is Kathyrn R. and C. Walton Lillehei Professor and
Director of the Densford International Center for Nursing Leadership at
the School of Nursing, University of Minnesota, Minneapolis, MN.
Jean Johnson is a Professor and Senior Associate Dean for Health
Sciences at The George Washington University, Washington, DC.
Pamela Mitchell is Elizabeth S. Soule Professor and Associate Dean for
Research at the School of Nursing, University of Washington, Seattle,
WA.
Dori Taylor Sullivan is an Associate Professor and Chair, Department
of Nursing at Sacred Heart University, Fairfield, CT.
Judith Warren is an Associate Professor at the University of Kansas
School of Nursing and Director of Nursing Informatics at Kansas
University Center for Healthcare Informatics, Kansas City, KS.
Reprint requests: Linda Cronenwett, PhD, RN, FAAN, Dean and
Professor, School of Nursing, University of North Carolina at Chapel
Hill, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460.
E-mail: [email protected]

Nurs Outlook 2007;55:122-131.
0029-6554/07/$–see front matter
Copyright © 2007 Mosby, Inc. All rights reserved.

doi:10.1016/j.outlook.2007.02.006