The authors of The Nun and the Bureaucrat tell us that one of the biggest weaknesses of traditional linear thinking is the belief that every effect has an immediate cause, that is, that cause and effect are directly linked. When a problem is discovered, people ask, "Why is this happening?" and they look for a solution. They argue logically that every effect has a direct cause, so they tend to focus on finding an immediate cause. What is actually happening is that what they are seeing are symptoms of a larger cause...the true root cause. So when they attempt to solve the symptom they have observed, they are simply applying a band aide and not really solving the problem. And when this happens, the same symptom will reappear later on.
What is really needed, in a systems thinking environment, is to link the chain of cause and effect until the true root cause is uncovered. Toyota taught both of these two healthcare organizations to continue asking why because most problems are much deeper than a single why? Both of these organizations learned to follow Toyota's "Five Whys" technique and as a result their problem solving was so much more effective.
In this wonderful book, the authors relate an example of how the PRHI group used the five whys to solve a problem with a medication cart. It seems as though they had just implemented some mistake proofing so as to eliminate breakdowns on the cart. They had found that the batteries on the computers that were supporting their bar code medication systems were very often going dead. At first they suspected operator misuse, so they incorporated color-coding and labeling of buttons, and some instructions to make its operation easy and obvious. In spite of all these precautions, they had a breakdown in the system, so the nurses applied the Five Whys technique to solve the problem. What they discovered, reinforced for them that the Five Whys is an effective tool for problem solving.
They traced the problem back to the battery charger, which they found did not actually have any power. And when they asked why it didn't have any power, they discovered that the electrical outlet was dead, so they asked why again. They discovered that the outlet was located right next to a sink and that the outlet had been splashed with water which shorted out the outlet. They didn't stop there...they asked why again and discovered that the water pressure in the sink was too high. They called a plumber to adjust the water pressure and the problem disappeared forever. Who would have thought that a battery going dead was linked to water pressure in the sink being too high? But that's how the Five Whys works.
Both organizations have used the Five Whys to solve many problems just like the Medication cart. They've used it to solve problems with drug and medication errors in the pharmacy. patient misidentification, and a host of other problems. The authors tell us to remember several very important things including:
- Cause and effect may be widely separated in time and space
- To eliminate cause may not be what it first seems to be.
- Ask "Why?" five times to find causes and make effective improvements and solve problems
- Redesigning processes safeguards improvements and frees staff to meet the needs of the patients.
- Computers can be helpful, but operators need systems knowledge, particularly in a complex hospital.
The key point in this posting is that solving problems requires that by using cause and effect logic and linkage you will be able to arrive at the true root cause of problems. So many times I've witnessed organizations focusing on the symptoms of problems rather than on the root cause. In fact, when you are able to identify that single core problem and solve it, most of the negative symptoms will typically disappear. The Five Whys is an excellent tool for creating this cause and effect linkage and if you are committed to using it, like these two healthcare organizations have done, your organization will solve many more problems. Remember, treating the symptoms of a disease is not the same as curing the disease.