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Pilot Plan Template
Ben McBride
A. Perform a root-cause analysis by doing the following:
The five-why analysis the CQI team implemented was not in-depth enough to produce the
root cause that the analysis was intended to expose. To strengthen the 5 Whys analysis
and gain a more comprehensive understanding of patient satisfaction at Shelbyville
Medical Center, the CQI team should focus on these key areas:
While a good start, the current 5 Whys analysis can significantly improve by broadening
its scope and integrating the following points.
1. Customer Input: While the Voice of the Customer (VOC) Report surveys patient
experiences, the 5 Whys analysis lacks direct patient feedback. The CQI team
should utilize patient focus groups or additional, more strategic surveys.
2. Varied Stakeholder Feedback: The existing analysis relied heavily on a limited
viewpoint. The CQI team should have broadened the stakeholder pool, providing
the different viewpoints needed to gain a more organic perspective.
3. Systemic Factors: The report hints at broader systemic issues, but the 5 Whys
analysis might not have adequately explored these. The CQI team needed to
continue asking questions beyond the “five whys”. The CQI team should have
considered Shelbyville Medical Center's policies and organizational culture, which
may have impacted the root cause of the issues raised in the Voice of the
Customer.
4. Emotional Aspects: The VOC report indicates several emotional components of
the overall patient experience. However, based on the CQI team's analysis, the
“Five Whys” may not have sufficiently analyzed these emotional aspects. A
patient's healthcare is very personal to patients, and this deep personalization can
affect patients' expectations of their experience (El-Haddad, 2020).
.
Confidential and Proprietary Information. ©
Western Governors University. All Rights Reserved
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
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Discuss whether the “why” cycle has been performed to a logical end in which additional questions would not
change the response.
First causal analysis
The “why” cycle was not performed correctly, nor did the cycle meet a logical
end. The first causal analysis was performed too narrowly and did not start at a
high enough level to determine an actual root cause. The CQI team needed to
analyze more than one issue. The analysis was incomplete because the root cause
did not define the “why” as to why it had been done this way since the start of the
hospital (Western Governors University, 2020).
Second causal analysis
The root cause of a training deficit is not defining the real issue. The CQI team
needed to keep asking questions to dive deeper into why there is a training deficit.
The “five whys” are a decent starting point; sometimes, continuing to ask
questions is required to determine the root cause (Western Governors University,
2020).
2. Using the template below, create an Ishikawa diagram using the information from the SIPOC Process
diagram from Task 1, and the five whys analysis.
SEE PAGE LAST PAGE
a. Explain the effectiveness of using the Ishikawa diagram to synthesize the results from multiple
information sources.
The effectiveness of the Ishikawa diagram is that the diagram points to the relationship
between the issue and the multiple possible causes (Lighter, 2013). The Ishikawa diagram
provides a visual tool for dealing with complex issues with a large amount of information.
The diagram also facilitates consideration of other inputs that may not have seemed as
obvious as a root cause (Sigma, 2021).
b. Discuss your assumptions about the organization, its processes, or both to complete the Ishikawa
diagram.
.
Confidential and Proprietary Information. ©
Western Governors University. All Rights Reserved
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
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*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
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D512 Pilot
TaskProgram
2.pdf2026/10/23Page
Task
1 of 13
2.pdf2026/10/23Page
1 of 13 1 of 13
Pilot Plan Template
Ben McBride
A. Perform a root-cause analysis by doing the following:
The five-why analysis the CQI team implemented was not in-depth enough to produce the
root cause that the analysis was intended to expose. To strengthen the 5 Whys analysis
and gain a more comprehensive understanding of patient satisfaction at Shelbyville
Medical Center, the CQI team should focus on these key areas:
While a good start, the current 5 Whys analysis can significantly improve by broadening
its scope and integrating the following points.
1. Customer Input: While the Voice of the Customer (VOC) Report surveys patient
experiences, the 5 Whys analysis lacks direct patient feedback. The CQI team
should utilize patient focus groups or additional, more strategic surveys.
2. Varied Stakeholder Feedback: The existing analysis relied heavily on a limited
viewpoint. The CQI team should have broadened the stakeholder pool, providing
the different viewpoints needed to gain a more organic perspective.
3. Systemic Factors: The report hints at broader systemic issues, but the 5 Whys
analysis might not have adequately explored these. The CQI team needed to
continue asking questions beyond the “five whys”. The CQI team should have
considered Shelbyville Medical Center's policies and organizational culture, which
may have impacted the root cause of the issues raised in the Voice of the
Customer.
4. Emotional Aspects: The VOC report indicates several emotional components of
the overall patient experience. However, based on the CQI team's analysis, the
“Five Whys” may not have sufficiently analyzed these emotional aspects. A
patient's healthcare is very personal to patients, and this deep personalization can
affect patients' expectations of their experience (El-Haddad, 2020).
.
Confidential and Proprietary Information. ©
Western Governors University. All Rights Reserved
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
4:03:13 AM1 of
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of
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Task
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, *@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
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Task
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2 of 13 2 of 13
Discuss whether the “why” cycle has been performed to a logical end in which additional questions would not
change the response.
First causal analysis
The “why” cycle was not performed correctly, nor did the cycle meet a logical
end. The first causal analysis was performed too narrowly and did not start at a
high enough level to determine an actual root cause. The CQI team needed to
analyze more than one issue. The analysis was incomplete because the root cause
did not define the “why” as to why it had been done this way since the start of the
hospital (Western Governors University, 2020).
Second causal analysis
The root cause of a training deficit is not defining the real issue. The CQI team
needed to keep asking questions to dive deeper into why there is a training deficit.
The “five whys” are a decent starting point; sometimes, continuing to ask
questions is required to determine the root cause (Western Governors University,
2020).
2. Using the template below, create an Ishikawa diagram using the information from the SIPOC Process
diagram from Task 1, and the five whys analysis.
SEE PAGE LAST PAGE
a. Explain the effectiveness of using the Ishikawa diagram to synthesize the results from multiple
information sources.
The effectiveness of the Ishikawa diagram is that the diagram points to the relationship
between the issue and the multiple possible causes (Lighter, 2013). The Ishikawa diagram
provides a visual tool for dealing with complex issues with a large amount of information.
The diagram also facilitates consideration of other inputs that may not have seemed as
obvious as a root cause (Sigma, 2021).
b. Discuss your assumptions about the organization, its processes, or both to complete the Ishikawa
diagram.
.
Confidential and Proprietary Information. ©
Western Governors University. All Rights Reserved
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
*@*^%^#!*&^*&^!()(@*&$*@10/23/2026,
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