The key to solving a problem is to first truly understand it. Often, we try to solve a problem before completely comprehending its cause, and the focus shifts too quickly from the problem to the solution. What we think is the cause, however, is sometimes just another symptom.
One way to identify the root cause of a problem is to ask "Why?" five times. When a problem presents itself, ask "Why did this happen?" Then, don't stop at the answer to this first question. Ask "Why?" again and again until you reach the root cause. This exercise can be surprisingly insightful in helping you figure out what is really going on, and can help you avoid "quick fix" solutions. It is especially useful for tackling chronic problems that show up over and over again in a system.
This technique is attributed to Taiichi Ohno, father of the Toyota Production System, which revolutionized automobile manufacturing.
Here is an example of how to ask "Why?" five times:
- Why is a patient's intravenous run rate wrong?
The previous nurse didn't change the run rate.
- Why didn't the previous nurse change the rate?
The doctor's order had gone to the pharmacy and the medication administration record (MAR) was not updated.
- Why wasn't the MAR updated?
The MAR is updated only once per day.
- Why is the MAR updated only once per day?
The hospital has chosen to use oral instructions for updates that happen more frequently.
- Why are oral instructions used?
The process was constructed a decade ago, when medication orders changed less frequently due to longer lengths of stay. Upon further study, the hospital determines that 40 to 50 percent of its medications change every day.
