Pilot Plan Template
v v
CreatevavpilotvplanvinvresponsevtovthevVOCvreportvfoundvinvthevcoursevusingvthisvtemplate.
A. Performvavroot-causevanalysisvbyvdoingvthevfollowing:
v
1. Critiquevthevcontinuousvqualityvimprovementv(CQI)vteam'svfivevwhysvanalysisvbyv
explainingvhowvitvcouldvhavevbeenvconductedvmoreveffectively.
ThevCQIvteam'svfivevwhysvanalysisvcouldvhavevbeenvimprovedvbyvfocusingvonvorvatvleastv
consideringvfailuresvinvsystemicvorvprocessvbreakdown.vItvreliedvtoovheavilyvonvonevspec
ificvdepartmentvandvdidn'tvidentifyvthevrootvcause.vAlso,vthevteamvstoppedvatvfivevquestio
nsvandvshouldvhavevaskedvmorevtovidentifyvthevrootvcause.vThevCQIvteamvneededvtovcon
ductvmorevthanvonevorvtwovfivevwhysvanalyses.vThevlowervthanvthevnationalvaveragevsco
resvonvthevVoicevofvthevCustomervReportvshowvthreevareasvofvconcernvthatvneedvtovbeva
ddressedvbyvthevCQIvteam,vandvonlyvonevwasvfoundvinvthisvanalysisv(VoicevofvthevCusto
mervReport,v2024).vIncludingvmorevquestionsvandvcompletingvmorevstudiesvwouldvbevm
oreveffectivevinvdeterminingvthevrootvcausevofvpatientvdissatisfactionvinveachvareavofvcon
cern.
a. Discussvwhethervthev“why”vcyclevhasvbeenvperformedvtovavlogicalvendvinvwhichva
dditionalvquestionsvwouldvnotvchangevthevresponse.
Includingvmorevquestionsvinvthisv5vwhyvanalysisvwouldvhavevkeptvthevresponsevthevs
ame.vWithvmorevquestions,vmorevissuesvmayvbevrecognized.vThev5vwhysvisvavone-
dimensionalvwayvofvevaluatingvandvmayv"missvmanyvofvthevunderlyingvproblemsvinv
numerousvprocessesvthatvledvtovtheverror"v(Lighter,v2013,vp.v114).
2. Usingvthevtemplatevbelow,vcreatevanvIshikawavdiagramvusingvthevinformationvfromvthev
SIPOCvProcessvdiagramvfromvTaskv1,vandvthevfivevwhysvanalysis.
a. ExplainvtheveffectivenessvofvusingvthevIshikawavdiagramvtovsynthesizevthevresultsvf
romvmultiplevinformationvsources.
AsvLighterv(2013)vdiscussed,vthevIshikawavdiagramvorvfishbonevisvavvisualvchartvsumma
rizingvmanyvdifferentvitemsvandvhowvtheyvfitvorvrelatevtovonevmajorvproblemvstatement.v
Thisvvisualvdiagramvisvlikevavtree,vwithvthevtrunkvbeingvthevproblem,vthevbranchesvbeingv
contributoryvfactors,vandvthevleavesvbeingvthevprocessesvandvconnectionsvorvcausevandv
effect.
b. Discussvthevassumptionsvthatvyouvmadevaboutvthevorganization,vitsvprocesses,vorv
bothvtovcompletevthevIshikawavdiagram.
InvcompletingvthevIshikawavdiagram,vIvmadevseveralvunderlyingvassumptionsvaboutvShe
lbyvillevMedicalvCenter.
Admission,vtriage,vandvbeddingvprocessesvmayvneedvtovbevupdated.
ConfidentialvandvProprietaryvInformation.v©vWesternvGovernorsvUniversity.vAllvRightsvReserved.
, Bedvavailability,vnursevcallvlightvfatigue,vandvoverworkedvstaffvmayvbevaddingvt
ovthevreasonsvpatientsvarevnotvreceivingvhelpvasvpromptlyvasvtheyvwouldvlike.
Physicianvcommunicationvstandardsvmayvneedvevaluation.
Dischargevteachingvandvprocessvmayvneedvtovbevexamined.
Staffingvshortagevmayvbevcontributingvtovdecreasedvpatientvsatisfaction
Thevonboardingvprocessvofvnewvhiresvandvagencyvnursingvneedsvtovbev
evaluated.
B. Usingvthevinformationvfromvthevroot-
causevanalysisvinvpartvAv(e.g.,vthevfivevwhysvanalysisvandvthevIshikawavdiagram)
vandvthevpreviouslyvcompletedvprojectvchartervfromvTaskv1,vdovthevfollowing:
1. Identifyvthreevopportunitiesvforvimprovement.
TimelyvcarevforvpatientsvreceivingvassistancevatvShelbyvillevMedicalvCenter.
1.
Patientsvwillvreceivevimprovedvcommunicationvfromvphysicians,vproviders,vandvstaffvduri
2. ngvtheirvstay.
Patientsvreceivevanvimprovedvunderstandingvofvtheirvdiagnosis,vcarevprocess,vandvdischa
3. rgevinstructions,vincludingvtreatmentvfollowingvdischarge.
2. Recommendvonevimprovementvstrategyvforveachvofvthevthreevopportunitiesvidentifiedvi
nvpartvB1.
Opportunity ImprovementvStrategy
#1 Improvevtriage,vbedding,vadmission,vcallvlight,vandvdischargevprocesses.
#2 WorkvwithvthevChiefvMedicalvOfficer,vEDvPhysicianvChair,vandvMedicalvStaffvCo
ordinatorvtovprovidevin-
servicevandvtrainingvonvcommunicationvskillsvthatvincludevactivevlistening,vcle
arvandvstraightforwardvlanguage,vandvopportunitiesvforvphysiciansvtovincludev
theirvpatientsvinvdecision-making
aboutvtheirvcarevplan,vtreatmentvoptions,vandvpotentialvrisks.
#3 WorkvwithvEducation,vIT,vEDvPhysicianvChair,vandvEDvDirectorvtovevaluate,vup
date,vreword,vandvrevampvdischargevteachingvmaterial.
3. Createvanvimprovedvprocessvflowchartvthatvrepresentsvwhatvanvidealvprocessvmightvl
ookvlikevconsideringvthevcurrentvShelbyvillevMedicalvCentervmodelvfromvTaskv1.
ConfidentialvandvProprietaryvInformation.v©vWesternvGovernorsvUniversity.vAllvRightsvReserved.
v v
CreatevavpilotvplanvinvresponsevtovthevVOCvreportvfoundvinvthevcoursevusingvthisvtemplate.
A. Performvavroot-causevanalysisvbyvdoingvthevfollowing:
v
1. Critiquevthevcontinuousvqualityvimprovementv(CQI)vteam'svfivevwhysvanalysisvbyv
explainingvhowvitvcouldvhavevbeenvconductedvmoreveffectively.
ThevCQIvteam'svfivevwhysvanalysisvcouldvhavevbeenvimprovedvbyvfocusingvonvorvatvleastv
consideringvfailuresvinvsystemicvorvprocessvbreakdown.vItvreliedvtoovheavilyvonvonevspec
ificvdepartmentvandvdidn'tvidentifyvthevrootvcause.vAlso,vthevteamvstoppedvatvfivevquestio
nsvandvshouldvhavevaskedvmorevtovidentifyvthevrootvcause.vThevCQIvteamvneededvtovcon
ductvmorevthanvonevorvtwovfivevwhysvanalyses.vThevlowervthanvthevnationalvaveragevsco
resvonvthevVoicevofvthevCustomervReportvshowvthreevareasvofvconcernvthatvneedvtovbeva
ddressedvbyvthevCQIvteam,vandvonlyvonevwasvfoundvinvthisvanalysisv(VoicevofvthevCusto
mervReport,v2024).vIncludingvmorevquestionsvandvcompletingvmorevstudiesvwouldvbevm
oreveffectivevinvdeterminingvthevrootvcausevofvpatientvdissatisfactionvinveachvareavofvcon
cern.
a. Discussvwhethervthev“why”vcyclevhasvbeenvperformedvtovavlogicalvendvinvwhichva
dditionalvquestionsvwouldvnotvchangevthevresponse.
Includingvmorevquestionsvinvthisv5vwhyvanalysisvwouldvhavevkeptvthevresponsevthevs
ame.vWithvmorevquestions,vmorevissuesvmayvbevrecognized.vThev5vwhysvisvavone-
dimensionalvwayvofvevaluatingvandvmayv"missvmanyvofvthevunderlyingvproblemsvinv
numerousvprocessesvthatvledvtovtheverror"v(Lighter,v2013,vp.v114).
2. Usingvthevtemplatevbelow,vcreatevanvIshikawavdiagramvusingvthevinformationvfromvthev
SIPOCvProcessvdiagramvfromvTaskv1,vandvthevfivevwhysvanalysis.
a. ExplainvtheveffectivenessvofvusingvthevIshikawavdiagramvtovsynthesizevthevresultsvf
romvmultiplevinformationvsources.
AsvLighterv(2013)vdiscussed,vthevIshikawavdiagramvorvfishbonevisvavvisualvchartvsumma
rizingvmanyvdifferentvitemsvandvhowvtheyvfitvorvrelatevtovonevmajorvproblemvstatement.v
Thisvvisualvdiagramvisvlikevavtree,vwithvthevtrunkvbeingvthevproblem,vthevbranchesvbeingv
contributoryvfactors,vandvthevleavesvbeingvthevprocessesvandvconnectionsvorvcausevandv
effect.
b. Discussvthevassumptionsvthatvyouvmadevaboutvthevorganization,vitsvprocesses,vorv
bothvtovcompletevthevIshikawavdiagram.
InvcompletingvthevIshikawavdiagram,vIvmadevseveralvunderlyingvassumptionsvaboutvShe
lbyvillevMedicalvCenter.
Admission,vtriage,vandvbeddingvprocessesvmayvneedvtovbevupdated.
ConfidentialvandvProprietaryvInformation.v©vWesternvGovernorsvUniversity.vAllvRightsvReserved.
, Bedvavailability,vnursevcallvlightvfatigue,vandvoverworkedvstaffvmayvbevaddingvt
ovthevreasonsvpatientsvarevnotvreceivingvhelpvasvpromptlyvasvtheyvwouldvlike.
Physicianvcommunicationvstandardsvmayvneedvevaluation.
Dischargevteachingvandvprocessvmayvneedvtovbevexamined.
Staffingvshortagevmayvbevcontributingvtovdecreasedvpatientvsatisfaction
Thevonboardingvprocessvofvnewvhiresvandvagencyvnursingvneedsvtovbev
evaluated.
B. Usingvthevinformationvfromvthevroot-
causevanalysisvinvpartvAv(e.g.,vthevfivevwhysvanalysisvandvthevIshikawavdiagram)
vandvthevpreviouslyvcompletedvprojectvchartervfromvTaskv1,vdovthevfollowing:
1. Identifyvthreevopportunitiesvforvimprovement.
TimelyvcarevforvpatientsvreceivingvassistancevatvShelbyvillevMedicalvCenter.
1.
Patientsvwillvreceivevimprovedvcommunicationvfromvphysicians,vproviders,vandvstaffvduri
2. ngvtheirvstay.
Patientsvreceivevanvimprovedvunderstandingvofvtheirvdiagnosis,vcarevprocess,vandvdischa
3. rgevinstructions,vincludingvtreatmentvfollowingvdischarge.
2. Recommendvonevimprovementvstrategyvforveachvofvthevthreevopportunitiesvidentifiedvi
nvpartvB1.
Opportunity ImprovementvStrategy
#1 Improvevtriage,vbedding,vadmission,vcallvlight,vandvdischargevprocesses.
#2 WorkvwithvthevChiefvMedicalvOfficer,vEDvPhysicianvChair,vandvMedicalvStaffvCo
ordinatorvtovprovidevin-
servicevandvtrainingvonvcommunicationvskillsvthatvincludevactivevlistening,vcle
arvandvstraightforwardvlanguage,vandvopportunitiesvforvphysiciansvtovincludev
theirvpatientsvinvdecision-making
aboutvtheirvcarevplan,vtreatmentvoptions,vandvpotentialvrisks.
#3 WorkvwithvEducation,vIT,vEDvPhysicianvChair,vandvEDvDirectorvtovevaluate,vup
date,vreword,vandvrevampvdischargevteachingvmaterial.
3. Createvanvimprovedvprocessvflowchartvthatvrepresentsvwhatvanvidealvprocessvmightvl
ookvlikevconsideringvthevcurrentvShelbyvillevMedicalvCentervmodelvfromvTaskv1.
ConfidentialvandvProprietaryvInformation.v©vWesternvGovernorsvUniversity.vAllvRightsvReserved.
