Health Care Tools and Techniques: Joint Commission Resources

Joint Commission Resources (JCR) is a wholly owned subsidiary of The Joint Commission. The mission of JCR is to improve the safety and quality of care in the United States and in the international community. Root Cause Analysis in Health Care: Tools and Techniques, JCR's reference manual, examines the root causes of sentinel events using the manufacturing process of Lean Thinking in combination with the business management strategy developed by Motorola called Six Sigma. This process is called Lean Six Sigma.

DMAIC

• DMAIC is a performance improvement model used by Lean Six Sigma that includes five phases: define, measure, analyze, improve and control. Team members seek cause or causes for the sentinel event occurrence during the analysis process to reach the most likely root cause.

Ishikawa's Seven Tools

• Performance improvement pioneer Kaoru Ishikawa, introduced seven basic quality control tools that he believed would enable 95 percent of workplace problems to be solved when skillfully implemented. These visual quality control tools are charts, graphs and diagrams.

  Check sheet

  Control Chart

  Fishbone diagram (cause-and-effect diagram or Ishikawa diagram)

  Flowchart (stratification)

  Histogram (frequency distribution)

  Pareto chart

  Scatter diagram

Histogram

• According to JCR, the purpose of a histogram is to provide a snapshot of the way data are distributed within a range of values and the amount of variation within a given process. The data then suggest where to focus improvement efforts. JCR suggests using stages: identifying proximate causes; identifying root causes; identifying opportunities for improvement; implementing and monitoring improvements.

Steps to Success

• Obtain the data sets and count data points

  Establish the range for the entire data set

  Divide the data into a set number of classes

  Establish the class width by dividing the range by the number of classes.

  Fix class boundaries

  Create the histogram

  Determine the number of data points in each class and create the bars

  Analyze findings