MMHA 6700 Week 8 Discharge Delay Fishbone Example

The Ride Was Never the Problem: A Fishbone and Five Whys Analysis of Late Discharges That Ends at the Morning Rounding Order

Student Name

Walden University

MMHA 6700: Healthcare Operations

Instructor Name

Month Day, Year

The Ride Was Never the Problem: A Fishbone and Five Whys Analysis of Late Discharges That Ends at the Morning Rounding Order

The Belief Being Tested

Ask anyone on the 5 West ward at Linden Ford, the invented hospital behind this term's operations work, why patients go home late, and they usually explain late discharges in one word: rides. Families arrive after work, the explanation goes, so patients leave in the late afternoon. The Week 7 value stream map found that the wait for a family ride is real, a median of 50 minutes, but that it is the fifth of six waits in sequence. This analysis uses a fishbone diagram to collect every cause staff could name, then follows the strongest causal chain with five whys, to test whether rides drive late discharges or are themselves an effect of something earlier.

Building the Fishbone

A fishbone, or cause-and-effect, diagram groups possible causes of a problem under headings, so a team considers more than the most obvious one. The problem placed at the head was: median time from medical readiness to leaving is 5 hours 50 minutes. A one-hour session with two hospitalists, three bedside nurses, the unit's case manager, one pharmacist and the transport supervisor produced the causes in Table 1, grouped under six headings commonly used in health care.

Table 1

Fishbone Causes by Category

Twenty causes across six categories. Rides appear once, under environment, as families' work schedules.

Five Whys on the Main Chain

The team then asked which causes, if removed, would shorten the wait the most. The value stream map showed the physician wait as the largest single delay, so the team traced it with five whys, asking why at each step until reaching a cause that could be changed.

The finding reverses the staff belief. Rides arrive late because the information families receive is late, and that information is late because of how morning rounds are ordered. Fix the rounding order and the call to the family can go out at 10:30 rather than 13:00.

Table 2

Five Whys From Late Departure

The chain ends at the rounding order. Rides are an effect: families come when they are told, and they are told after lunch because the order comes after lunch.

Checking the Chain

Five whys is easy to misuse. A critique of the method in health care warns that it tends to follow a single linear path, can stop at whatever cause the team already believes and may miss the several interacting causes most problems have (Card, 2017). The team guarded against those weaknesses in three ways.

First, they kept the fishbone's other causes in view. Late nurse notification and pharmacy filling remain real and will be addressed, but they come after the order is written, so they cannot explain why the order is late. Second, they checked the chain against data. In the 40 discharges mapped in Week 7, the 9 patients rounded on first, by chance of room order, left a median of two hours earlier than the others. Third, they asked whether families could come earlier if told earlier. The case manager called families for 10 planned discharges the day before; 8 could arrive before noon.

Studies of hospitals that set a goal of discharging patients before noon found that changing rounding and team routines moved discharges earlier (Wertheimer et al., 2014). Another analysis found that earlier discharge was associated with shorter length of stay for medical patients, though not for surgical patients, which suggests the benefit is real but not universal (Rajkomar et al., 2016).

Countermeasures

Table 3

Countermeasures Linked to Causes

The first three countermeasures address the main chain; the last two address secondary causes the fishbone surfaced.

Limits

The fishbone reflects the views of one session's participants. Five whys found one chain; others may contribute, especially for patients discharged to facilities. The comparison of patients rounded on first was not randomized; those patients may have been less complex. The session also lacked a family member's view, which might have added causes the staff do not see, such as unclear instructions about when to come.

Conclusion

The ride is real, but it is not the cause of late discharges on 5 West. It is the last link in a chain that begins with how morning rounds are ordered. The fishbone kept other causes visible, the five whys followed the main chain and the hospital's own data supported it. Changing the rounding order, and telling families earlier, attacks the chain at its start.

References

Card, A. J. (2017). The problem with '5 whys'. BMJ Quality and Safety, 26(8), 671-677. https://doi.org/10.1136/bmjqs-2016-005849

Rajkomar, A., Valencia, V., Novelero, M., Mourad, M., & Auerbach, A. (2016). The association between discharge before noon and length of stay in medical and surgical patients. Journal of Hospital Medicine, 11(12), 859-861. https://doi.org/10.1002/jhm.2529

Wertheimer, B., Jacobs, R. E., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154