SECTION IV BACKGROUND: CLARIFYING THE PROBLEM
The intent of this section is to work through the causative factors to fully understand the clinical problem. The focus is to use a root cause analysis approach to examine the big picture and pull out the factors that contribute to the problem.
In this section, you will use information provided from previous sections of the case study and your research to create a root cause analysis. If needed, create scripts from the perspective of the various stakeholders who might be involved with the process being investigated to illustrate the various perspectives.
Use the Healthcare Quality Improvement Partnership’s Root Cause Analysis for Clinical Audit guide (accessible at www.hqip.org.uk/resources/using-root-cause-analysis-techniques-in-clinical-audit/) to guide the students through a root cause analysis. Complete the cause–effect or fishbone diagram. A resource that includes a fillable template for creating a cause–effect diagram can be accessed through the Institute for Healthcare Improvement (a free account is required, accessible at www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx).

Chapter 12 Patient Safety includes an example of a root cause analysis.

The clinical nurse specialist (CNS) decides to work through a root cause analysis and use a cause–effect diagram (fishbone diagram) with the team to identify potential causes for catheter-associated urinary tract infections (CAUTIs). You work with the CNS to complete this activity with the team.
SECTION V BACKGROUND: PLANNING FOR CHANGE The intent of this section is to create a preliminary plan for action by using the PLAN-DO-STUDY-ACT model as outlined in chapter 13.
The team decides to use the Plan-Do-Study-Act model to determine small tests of change that can be undertaken to improve CAUTI’s in the patients the team cares for. You work with the team to develop a map of the PDSA model.