Title: Quality Improvement Project: Using Problem and Solution fishbone
diagrams
Competency category:
• evidence-based_practice
• quality_improvement
Learner level:
• Pre-licensure BSN
• RN to BSN
• Graduate
Learning setting:
• Clinical settings
• Online or web-based modules
• Classroom
• Independent study
Type of strategy:
• Case studies, problem-based learning assignments, reflective practice
exercises
• Paper assignments
Learning objectives:
Pre-licensure:
• QI: Seek information about outcomes of care for populations served in
care setting
• QI: Appreciate the value of what individuals and teams can to do to
improve care
• EBP: Participate in structuring the work environment to facilitate
integration of new evidence into standards of practice
• Teamwork and Collaboration: Clarify roles and accountabilities under
conditions of potential overlap in team member functioning
Graduate:
• EBP: Initiate changes in approaches to care when new evidence warrants
evaluation of other options for improving outcomes or decreasing adverse
events
• QI: Use a variety of sources of information to review outcomes of care and
identify potential areas for improvement
• QI: Appreciate that continuous quality improvement is an essential part of
the daily work of all health professionals
Strategy overview:
• I start out with this quote: Albert Einstein: "We can't solve problems by
using the same kind of thinking we used when we created them."
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I have used these fishbone diagrams for classroom discussions, didactic
assignments and clinical assignments. They are effective in each setting.
I have used these as the basis of discussion/assignments related to these
Adverse Events: The Lewis Blackman Story Video
(http://www.qsen.org/video/) and First Do No Harm
(http://www.p4ps.net/guides/p4psbrochure.pdf). The post-licensure BSN
students rated this as one of the most helpful assignments they had in an
EBP/Research course.
Use both the problem and solution diagrams. The problem one is common
and I developed the solution one to assist students in making evidencebased practice recommendations. They need to use both to make the
connection between problems and solutions. I tried using just one as a
stand-alone activity and it didn’t work.
Sources of evidence: Use of the diagrams emphasizes that EBP draws
from nurse expertise, patient preference and the literature. Have them find
and incorporate an EBP article pertinent to the solution.
Have students bold the items they assess as key to the problem and the
solution. This helps students prioritize causes and identify a key solution.
File format: Here is a website for the QSEN Quality Improvement Project
Fishbone problem and solution assignment:
http://www.sonoma.edu/users/k/koshar/n303/qsen.htm. They are set up similarly
in each course. You will also find a link to well-done QI problem and solution
fishbone diagram examples. Feel free to use all or any part of this information
and just cite us as the source.
Evaluation: Here is the evaluation rubric I developed.
Quality Improvement Grading Criteria
Completes the Fishbone Problem and Solution Diagrams. Clearly states the problem and solution. B
the item(s) (i.e. under people, equipment) that you assess as being key to the problem and solution.
Includes at least one item in each of the six categories (i.e. People, Processes, etc).
Uses the 6 areas of competencies: Patient Centered Care, Teamwork and Collaboration, EvidenceBased Practice, Quality Improvement, Safety and Informatics.
Evidence: uses each of the 3 sources of evidence (patient preference, nurse expertise, the literature
Cites at least one EBP article in the solution diagram. Briefly explain how it informs your solution.
Is succinct
Clinical Presentation
Total