C983
Quality Improvement in Healthcare
TASK 2
Pilot Plan Template
(Passed First Attempt)
Western Governors University
, Student Note: the following represents the basic Task components. Be sure to review the rubric before
submitting to ensure that all salient points are addressed.
Task 2
A. Perform a root-cause analysis by doing the following:
1. Critique the continuous quality improvement (CQI) team’s five whys analysis by explaining
how it could have been conducted more effectively.
There were only two different analyses completed and each was focused on a small,
specific piece of the much larger department. While the analyses did identify some
problem areas, they did not continue asking questions to drill down to the root
causes of the current workflow issues. To complete a more thorough and effective
analysis, the team needs to complete more analyses to identify all pain points within
the department and continue asking questions in each one until a true root cause has
been identified for each issue.
a. Discuss whether the “why” cycle has been performed to a logical end in which additional
questions would not change the response.
The why cycle has not been performed through to the end in which no further
questions could be asked. The first analysis successfully identified a root cause of
low patient satisfaction with physician communication however, it is focused on one
specific area and is not likely to be the only root cause to this problem. Additional
analyses will need to be performed to identify all possible causes. The second
analysis also addressed the root cause of low patient satisfaction with physician
communication and identified that the physicians feel rushed due to high wait times
caused by a bottleneck between patients seeing the resident and attending
physicians. The analysis identified the root cause of this bottleneck as poor
communication between physicians due to a lack of proper training. Questions
should have continued to drill down to a true root cause by identifying what the
current training is and what specific component is missing that is causing the poor
communication.
2. Using the attached template, create an Ishikawa diagram using the information from the
process flowchart, SIPOC map (from Task 1), and the five whys analysis.
a. Explain the effectiveness of using the Ishikawa diagram to synthesize the results from
multiple information sources.
Utilizing the Ishikawa diagram allows all pertinent data to be viewed at the same
time and in one location. By compiling the information this way, it is easier to
analyze and then quickly identify the largest problem areas. For example, grouping
known issues into specific categories simplifies the process of identifying which area
has the most potential for improvement.
This study source was downloaded by 100000902171055 from CourseHero.com on 11-16-2025 18:13:51 GMT -06:00
https://www.coursehero.com/file/101040188/C983-Task-2-Ann-Flaggdocx/
Quality Improvement in Healthcare
TASK 2
Pilot Plan Template
(Passed First Attempt)
Western Governors University
, Student Note: the following represents the basic Task components. Be sure to review the rubric before
submitting to ensure that all salient points are addressed.
Task 2
A. Perform a root-cause analysis by doing the following:
1. Critique the continuous quality improvement (CQI) team’s five whys analysis by explaining
how it could have been conducted more effectively.
There were only two different analyses completed and each was focused on a small,
specific piece of the much larger department. While the analyses did identify some
problem areas, they did not continue asking questions to drill down to the root
causes of the current workflow issues. To complete a more thorough and effective
analysis, the team needs to complete more analyses to identify all pain points within
the department and continue asking questions in each one until a true root cause has
been identified for each issue.
a. Discuss whether the “why” cycle has been performed to a logical end in which additional
questions would not change the response.
The why cycle has not been performed through to the end in which no further
questions could be asked. The first analysis successfully identified a root cause of
low patient satisfaction with physician communication however, it is focused on one
specific area and is not likely to be the only root cause to this problem. Additional
analyses will need to be performed to identify all possible causes. The second
analysis also addressed the root cause of low patient satisfaction with physician
communication and identified that the physicians feel rushed due to high wait times
caused by a bottleneck between patients seeing the resident and attending
physicians. The analysis identified the root cause of this bottleneck as poor
communication between physicians due to a lack of proper training. Questions
should have continued to drill down to a true root cause by identifying what the
current training is and what specific component is missing that is causing the poor
communication.
2. Using the attached template, create an Ishikawa diagram using the information from the
process flowchart, SIPOC map (from Task 1), and the five whys analysis.
a. Explain the effectiveness of using the Ishikawa diagram to synthesize the results from
multiple information sources.
Utilizing the Ishikawa diagram allows all pertinent data to be viewed at the same
time and in one location. By compiling the information this way, it is easier to
analyze and then quickly identify the largest problem areas. For example, grouping
known issues into specific categories simplifies the process of identifying which area
has the most potential for improvement.
This study source was downloaded by 100000902171055 from CourseHero.com on 11-16-2025 18:13:51 GMT -06:00
https://www.coursehero.com/file/101040188/C983-Task-2-Ann-Flaggdocx/
