STRUCTURED PROBLEM SOLVING

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATION

© CAHO 2020-21. All rights reserved

Every problem has a solution. You just have to be
creative enough to find it.

-Travis Kalanick,
Co-founder of Uber

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 Overview of the Presentation

 Definition - Correction, Corrective and Preventive Actions

 Structured Problem Solving
 Tools and Techniques - Structured Problem Solving
 Implementation and follow up

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 Continual Improvement

 Perfection of systems does not happen overnight

 Quality management strives to achieve continual improvement
 Essence of continual improvement is effective problem solving

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 Correction, Corrective and Preventive Action

 Correction - Action to eliminate a detected non-conformity.

 Corrective Action - Action to eliminate the cause of a detected non-conformity.
 Preventive Action - Action to eliminate the cause of a potential non-conformity.

(As per ISO 9000:2005 sec 3.6)

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 Correction

Correction - Action to eliminate a detected non-conformity.

 Correction is like a first aid.
 Instant action taken to correct the problem.
 Action to reduce the impact of the problem.

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 Corrective Action

Corrective action - Action to eliminate the cause of a detected non-conformity.

 Reactive
 Considered as ‘Problem Solving’
 Focuses on root cause/ causes.
 Steps taken to remove or eliminate the causes of a non-conformity or
undesirable situation.
 Intent is to ensure non-conformity or undesirable situation do not re-occur
(to avoid recurrence).

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 Preventive Action

Preventive action - Action to eliminate the cause of a potential non - conformity.

 Proactive
 Undesirable situation has not happened.
 Need to anticipate risks that may occur.
 To be identified proactively, against the potential non-conformities, risks or
defects.
 To prevent occurrence.

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 Examples – C, CA, PA

Food served cold to patient, replaced with hot food when complained C

Metal detector at the entrance of MRI room PA

Alcohol based hand rub kept at the bedside of patients as the hand hygiene
CA
compliance of doctors and nurses was inadequate
Patients monitored post endoscopy in the recovery area PA

Inj. Avil administered to the patient as he developed rashes and chills with
C
blood transfusion

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 Fire due to Old Wiring and Poor Insulation

 Correction: Put off the fire immediately

 Corrective Action: Change the old wiring in the area
 Preventive Action: Thermographic testing of the electrical wiring at predefined
intervals

Thermography is a non-destructive test method to detect poor connections, unbalanced

loads, deteriorated insulation in energised electrical components. Heat generated is
related to the amount of current flowing and the resistance. As components deteriorate,
their resistance increases, causing a localised increase in heat.

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 Wrong Patient Sent to Operation Theatre

Kumar. V for angiogram sent to CTVS OT for CABG instead of Kumar. S from the same
ward. Identified at the receiving bay by the Anaesthetist & Nurse, while checking the
identity, procedure using the surgical safety checklist (Pre-op check).
 Correction : Patient counselled by the doctor and sent to the CATH lab
 Corrective Action : Systems to alert the medical staff in wards when patients with
same name, or similar sounding names are admitted. Colour tagging with different
coloured bands and double checking.
 Preventive Action : Surgical safety checklist is used to prevent wrong surgery, wrong
patient and site, which has worked in this case.
However, the PA based on this experience is to ensure that the same cause cannot be a
potential problem in other areas. For example, patients with same name waiting for CT/
MRI, OPD to see the Doctor, Dialysis etc.

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 Baby Sustained Burns

Four month old baby for cardiac surgery at 7.30 am was given bath by night duty nurse at
5.30 am with hot water as part of pre-op preparation. Nurse checked the temperature of
the hot water with her gloved hands by pouring water on her gloved wrist. Baby
sustained burns.

 Correction: Treatment provided to the baby

 Corrective Action: Temperature checking of the hot water for bath to be done with
thermometer.
 Preventive Action: Temperature checking made mandatory with bath thermometer
in wax bath, foot therapy for diabetic wound patients, sitz bath.

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 Prevention Emphasised through
Risk Based Thinking

 Previous versions of ISO 9001 included correction, CA and PA.

 No mention of PA in ISO 9001:2015.
 ISO 9001:2008 didn’t mention risk and 2015 mentions risk in various forms
and contexts.
 Clause 6.1 of ISO 9001:2015 has new requirements to risk when planning
QMS.
 It also requires evaluation of the effectiveness of the actions to address risk.

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 Structured Problem Solving

Traditional Approach Structured Approach

PROBLEM PROBLEM

SOLUTION
SOLUTION (PREVENT
(QUICK FIX) RECURRENCE/
OCCURRENCE)

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 Traditional Vs Structured Problem Solving

Traditional Approach Structured Approach

 Jump to conclusions  Identifying root cause
 Treating the symptoms
 Identifying all associated causes
 Not evidence/ data driven
 Evidence/ data driven
 Short term focus
 Long term focus
 No follow up
 Follow-up of recommendations
and implementations

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 Forming the Right Team

 Team better than individual.

 Multidisciplinary group with members from
area that experienced problem.
 Small team, knowledge about the system.
 Administrator/ decision maker, client of the
process, quality team member.
 Clear purpose, roles.
 Mutual accountability, complimenting each
other.

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PDCA – Approach to Problem Solving

ACT PLAN

CHECK DO

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Steps in PDCA Problem Solving

1 DEFINE THE PROBLEM

2 ANALYZE THE PROBLEM

PLAN
3 GENERATE SOLUTIONS

4 SELECT THE SOLUTION

5 IMPLEMENT DO

6 EVALUATE THE RESULT CHECK

7 STANDARDIZE ACT

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 1. Define the Problem

 Most difficult and most important step.

 Problem well defined is problem half solved.
 Involves situation diagnosis to focus on real problem and not symptoms.
 Written down, clear, specific.
 Details of who, what, where and when.
 GEMBA- Walk the area, look for potential causes, observe, take inputs, pictures.
 Careful defining provide raw material for successful identification of root cause.
(Appropriate tools include brainstorming, fishbone, flow chart, pareto charts, check
sheets and histograms.)

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2. Analyze the Problem - RCA

SYMPTOMS
 Problem reported

CAUSES
 Reasons of the problem
 Root

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 Root Cause Analysis

 Weed is the problem, which is above the surface and easy to see.
 Root is beneath the surface, its obscured and difficult to get to.
 Mistake in understanding is that RCA is to identify the root cause of the problem.
 Analysis is actually breaking down into parts.
 Root is a system and a combination of parts.
 RCA is to understand all the pieces that contribute to the problem.
 Not all the causes are equally important - need to treat the important.

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 5 Why Analysis

 Called the two year old approach.

 Often used to solve simple or moderate problems.
 Simple tool that helps to get to the root immediately.
 Made popular in 1970s by the Toyota production system.
 Involves asking repeated “Why”.
 Answer to the first “why” leads to the second “why”.

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 5 Why Analysis - Needle stick injury
Problem: Housekeeping staff sustained needlestick injury while transporting the
sharps to the temporary storage area.
Why: Why did the housekeeping
The box was overflowing.
staff sustain needle stick injury?

Why: Why was the box There is a shortage in supply of

overflowing? puncture proof boxes.

The order for a new set of boxes was

Why: Why was there a shortage?
not placed by stores on time.
Why: Why was the order not
The storekeeper was on leave.
placed on time?

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 Patient LATE to OT
Problem: Patient arrives late to OT from the ward. Surgeon, anaesthetist and the
team had to wait for the patient.

Why: Why did the patient arrive late to OT? Patient had to wait for the trolley.

Replacement trolley had to be brought

Why: Why did the patient wait for the trolley?
from another ward.
Why: Why did the patient need a replacement Screws of the side rail of the trolley had
trolley? dislodged.

Why: Why did the screws dislodge? Screws were not checked periodically.

Due to absence of preventive maintenance

Why: Why were they not checked periodically?
schedule.

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 Criticism of 5 Why Analysis

1. Tendency to stop at symptoms rather than going on to root causes.

2. Inability to proceed beyond the investigators current knowledge.
3. Results not repeatable- different people using 5 whys come up with
different causes for the same problem.
4. Isolate single root cause, when there could be many root causes.

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 Cause and Effect Diagrams

Dr. Kaoru Ishikawa

Cause and Effect Diagram (Fishbone or Ishikawa diagram)
 It is a schematic way of relating the causes of variation in a process.
 A drawing to organize the contributing causes to a problem in order to prioritise,
select, and improve the source of the problem.
 Problem (Effect) on the right side and the possible causes on the left side.

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 When is it used?

 When identifying possible causes for a problem.

 Identifies areas for collecting data.
 Good process knowledge from multiple stake holders.
 Useful for teams: focusing a discussion and organizing large amounts of
information coming from a brainstorming session.
 Especially when a team’s thinking tends to fall apart, and concentration is lacking.

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 Cause and Effect Diagram

Material People /Man Policies

New staff Staff can cut the queue

Registration at any time

Irrespective of appointment time
Aggrieved Staff
Inadequate stationeries

Registration
Unnecessary information being Manual registration- No computers
time too long
collected at the reg. counter

FIFO not followed

Inadequate signage / instruction
Separate line for men and
women

Procedures / Methods Plant / Machine

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 Pareto Charts

 Pareto charts are used to identify and prioritize problems to be solved.

 Vilfredo Pareto, 1800, Italian economist noted “80% of wealth was held by 20% of
population”.
 Juran applied the Pareto Principle, stating that 80% variation in process is by 20% of the
variables.
 “Vital few” as opposed to “Trivial many”.
 80/20 rule.
 Need not be 80/20, could be 75/25 or 70/30 or even 65/35 also and even disproportionate
like 75/35.
 The concept is to prioritise and address the issue.

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 When is it used ?

 Looking at data on the frequency of problems or causes.

 When there are too many problems or causes and you want to focus on the
significant ones.

 When you want to analyse broad causes by looking at their specific components.

 To effectively communicate to others about the problem/ data.

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 Dissatisfaction of Patients in OPD

Number of In % Cumulative
S.No Reasons
patients (N=400) frequency
7 Registration Time too long 111 28 % 28%
3 Insufficient Doctors 100 25 % 53%
4 Insufficient Counter Staff 93 23 % 76%
2 Problem mixing with ‘follow-up’ patients 25 6% 82%
6 Too many patients at the same time 21 5% 87%
1 No mike or display board to know the token number 15 4% 91%
8 No name boards of the doctors 13 3% 94%
5 Staff not following the Queue 12 3% 97%
9 Others 10 3% 100%
10 Total 400

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Addressing these 3 issues out of 9, will solve 76% of the problems
120 94% 97% 100% 100%
91%
87%
82%
100 76% 80%

80
53% 60%

60
40%
40 28%

20%
20

0 0%
Registration Insufficient Insufficient Problem mixing Too many No mike or No name Staff not Others
Time too long Doctors Counter Staff with ‘follow-up’ patients at the display board to boards of the following the
patients same time know the token doctors Queue
number

Number of patients Cumulative frequency

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 3. Generate Solutions

 Brainstorm solutions.

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 4. Prioritise/ Select solutions

LARGE
PLAN DO
NOW NOW
Impact

DON’T DO
DO LATER

SMALL
DIFFICULT EASY
Ease of implementation

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 5. Implement the Solutions

 Involve the stakeholders.

 Appropriately communicate to the stakeholders and create ownership.
 Draw up the implementation plan and the timelines.
 Identify the implementation champion/ leader.
 The RCA team should be involved in implementation for better results.
 5a. Verification - Did the solution get implemented?

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 6. Evaluate the Result

Conduct a pilot study to assess the following:

 The changes after implementation.
 Effectiveness of the solution and whether any further solution needs to be
implemented.
 Validation - Has the solution produced the desired results?
 Whether the stakeholders and the RCA team are satisfied with the solution and
implementation.

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7. Standardise

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 Implementation and Follow up

 Role of Quality Team is critical in follow up.

 Continuous audits for a certain period.
 Periodical audits after the standardisation is achieved.

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 References

1. Where is preventive action?, John E. Jack, Charles A. Cianfrani, http://asq.org/quality-

progress/2016/03/standards-outlook/where-is-preventive-action.html
2. CAPA Process (Corrective Action & Preventive Action), Bill Greenwood, www.thebcma.org
3. Root cause analysis processes and methods, http://asq.org/learn-about-quality/root-cause-
analysis/overview/conducting-root-cause.html
4. TQM in the Service Sector, R.P Mohanty & R.R Lakhe, Jaico Publishing House
5. Total Quality Management, V.S Bagad, Technical Publications Pune
6. Juran’s Quality Handbook, 6th Edn, Joseph M. Juran & Joesph A. De Feo, Tata McGraw-Hill
7. Learn Quality Tools, http://asq.org/learn-about-quality/quality-tools.html
8. Quality Improvement tools & techniques, Peter Mears, McGraw-Hill
9. Root cause analysis – A Tool for Total Quality Management, Paul F. Wilson, Larry D.
Dell, Gaylord F. Anderson

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Any Questions

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Thank You!

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