Safety Performance Improvement Assignments

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.