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, D512 Pilot Plan Template Western Governors University
Pilot Plan Template fh fh
Create a pilot plan in response to the VOC report found in the course using this template.
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A. Perform a root-cause analysis by doing the following:
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1. Critique the continuous quality improvement (CQI) team’s five whys analysis by
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explaining how it could have been conducted more effectively.
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The Voice of the Consumer Report lays out multiple different matters that
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Shelbyville Medical Center has room to improve on. SMC falls below the national
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benchmarks thus giving room for improvement (“Voice of the Consumer Report”,
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n.d.). The CQI’s five whys analysis could have been conducted more efficiently by
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focusing on more than one root cause/issue. It is important to understand that
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patient dissatisfaction at Shelbyville Medical Center’s ED is not straightforward and
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has many components that need to be addressed and reviewed. There needs to be
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a more thorough examination of the problems that patients are experiencing to
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come up with a plan of action for improvement.
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a. Discuss whether the “why” cycle has been performed to a logical end in which
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additional questions would not change the response.
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Reviewing if the five why cycle was performed to a clear and logical end, I believe
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that this was performed accurately by the CQI task team. As discussed by Lighter
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(2013), “In many cases the five “Whys” are sufficient, but sometimes, the
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technique will continue beyond that level as new issues are recognized (p. 114-
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115). In this case, the final response does seem to have a logical end to where
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while additional questions may provide additional clarification, it would likely not
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change the overall response.
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2. Using the template below, create an Ishikawa diagram using the information from
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the SIPOC Process diagram from Task 1, and the five whys analysis.
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a. Explain the effectiveness of using the Ishikawa diagram to synthesize the results
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from multiple information sources.
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Using the Ishikawa diagram to synthesize results from these sources is extremely
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effective as it can point out the processes and connections that are causing
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dissatisfaction within the Shelbyville Medical Center Emergency Department. The
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CQI team can use both the Ishikawa diagram and the SIPOC map to help target
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key issues to improve patient satisfaction in the Shelbyville Medical Center
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Emergency Department. The SIPOC map can give SMC’s leadership a clear picture
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of each step of the patient’s visit from intake to discharge and comprehend what
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areas are requiring improvement innovations.
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