A Practical Guide to Quality Improvement for Burn Care

UNDERSTANDING THE PROBLEM

Fishbone diagram, also known as a cause and effect diagram, aims to help us identify the possible causes of an event, outcome or issue. To help us consider the issue from different perspectives the diagram breaks down the potential causes into the following categories: equipment, process, people, materials, environment and management.

Example: Patricia used a fishbone diagram for her project on hand hygiene:

FISHBONE DIAGRAM

PEOPLE

MATERIAL

No team leaders Workload

EQUIPMENT

No towels

Inadequate personal hand rub bottles

Some sinks no water

No hand rub dispensers

Inadequate sinks and taps

Skin drying

Having no hand rub

No checklists

Inadequate staff

Having no soap

POOR HAND HYGIENE AMONG HEALTH CARE WORKERS

Role models

Training

No guidelines in rooms

Inadequate space in some rooms

No task allocation

Some sinks are closer than others

No supervision

ENVIRONMENT

OTHER

METHOD

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