Fishbone diagram on Quality Improvement

NUR 440 Caring Nurse Leadership Quality Improvement Diagram   Problem is Reducing medication errors. Why medication errors What causes it Who is affected How do you reduce it.           Appendix B QualityImprovement Case Study  Think about a system process that you have been concerned about. What went wrong during this process? What caused the problem, and how could we provide higher value, higher-quality care?    Identify the problem and create a clear, specific problem statement  Write the problem statement at the head of the fish.    Brainstorm the major categories of causes of the problem. Consider the following as categories: People, Materials/Equipment, Environment, Culture, Policy/Procedure, Clinical Care.    Write the categories as branches from the main arrow in the shaded boxes on the diagram.    Brainstorm all of the possible causes of the problem. Ask, “Why does this happen?” For each (primary) cause, write it as a branch from the appropriate category. These causes may be written in more than one place if they relate to more than one category.    On the fishbone problem diagram, highlight those areas where the most opportunity for change exist. Remember that this should be something that the nurse leader can impact.    Create a 10 minute presentation that provides a synopsis of the problem, the highlighted areas of opportunities, and suggested corrective actions. You can either bring a poster sized copy of your diagram or project it for your peers. Your suggested actions should be grounded in evidence. In QI this evidence should be the literature and opinions of involved stakeholders.     Quality Improvement Case Study Rubric     Points Completes a Fishbone Diagram. Clearly states the problem. 2 Includes at least three substantive items in each of the six categories for problem diagram. 3 Evidence that the five “whys” technique was utilized. 2 Cites at least one EBP article in the solution diagram. Briefly explain how it informs your solution. 2 Bold the item(s) (i.e. under categories) that are priority areas of opportunities for action in the diagram. 1 Completes presentation and includes a clear description of the problem, areas of opportunity, and suggestions for action. 5 Total

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