The Five Whys

• Where are the quality problems and which problems should I tackle first?
• Ishikawa / Fishbone / Cause & Effect Diagrams
• Process Mapping
• Five Whys
• Pareto Charts
• Failure Modes & Effects Analysis
• Root Cause Analysis

This is a simple brainstorming tool to get to the root causes of a problem.  State the problem, and, like an inquisitive toddler, keep asking why in response to each suggested cause. Ask as many ‘why’s as you need. 

Example:

Q1:  Why is there a line up at the pharmacy at lunch hour?
A1:  Because customers want to be served during their lunch break, and one of the pharmacists is usually on lunch.


Q2:  Why is one of the pharmacists usually on lunch?
A2:  Because that’s the way we’ve always done it. 

Q3:  Why?

Perhaps we could reschedule lunch breaks…

The 5 Why’s can help you get to a root cause, which then reveals a possible change that you could make to improve quality. 


Advanced Tips for Five Whys

There may be multiple explanations at any of the why questions.  Consider, for example:

Q:  Why do Dr. Jones’ office appointments always run so late at mid-morning?
A:  Because he’s always running late from his hospital rounds before clinic. 

Guard against the tendency to gravitate towards any single cause that you might have a bias towards.  This could lead you to ignoring other possible causes.  Upon further reflection, you might realize there are other explanations:

A:  Because Dr. Smith likes to chat with his patients, he doesn’t leave enough time for the complicated cases, and he’s always running late from his hospital rounds. 

Here are some tips if you encounter multiple causes at a particular ‘why’ question: 

Tip: Do an Ishikawa diagram first, and then use 5 Why’s to dig deeper into the branches that the QI team believes are most important. 

Tip: Try 5 why’s with each of those different causes that you feel they are important. 

For example: 

• Why does Dr. Smith like to chat with his patients? Why? Why? Why?
• Why doesn’t he leave enough time for the complicated cases?  Why?  Why? Why?
• Why is he always running late from his hospital rounds?  Why?  Why?  Why?
  

Tip:  Drill deep only into the causes where you can make a change. 

Example:  in the pharmacy example above, imagine if you drilled down into why customers want to get served on their lunch hour.  You’d find that their employers won’t give them lunch hours at other hours.  This is not something you are likely to change, and in any case, it is your desire to deliver patient-centred care.