The Big So What

Asking More Questions, A New Year’s Resolution

One of our mantras here at PointRight is “So What?” Whenever a colleague brings up an issue, observation or factoid in a meeting, invariably someone asks the big “So What?”  It’s not intended to be the dismissive retort of your typical teenager, but a call for all to consider so much more than just the issue at face value. In most instances, the discussion becomes much deeper and more meaningful than the original statement and frequently leads us into an unexpected course of action. But the action steps are clearer and more focused. My take-away during my short tenure here at the Point is that we can never stop asking questions.

So What… Are My Favorite Questions?

Coming up with a standardized set of questions can help you routinely process challenges. When faced with a new finding or market problem, my favorite questions to ask myself include:

• So what is this telling me?
• So what will the impact be to me? To others?
• So what will happen if I ignore this?
• So what will this mean to my current workflow?
• So what other data do I need to explore further?

Five-Stars Meet The Five Why’s

The New Year’s resolution that I’m sticking to for 2020, the year of clearer vision, is to resolve to ask more questions. For facility leadership, a great place to start might be with Five-Star Ratings. Consider your areas of greatest challenge; is it staffing? Is it a particular quality measure? Is it repeat deficiencies in health inspections?  It is likely that you have asked questions and delved into the root cause analysis. But did you go far enough? Perhaps reframing the question or digging down deeper with a different set of questions could elicit new findings. It’s a fundamental activity in any quality improvement program.

Maybe you’ve heard of the Five Why’s approach or perhaps you already employ this method of root cause analysis. If you don’t, here’s a little detail. Sakichi Toyoda, the Japanese industrialist, inventor, and founder of Toyota Industries, developed the Five Why’s technique in the 1930s. The method is quite simple and can be used on your most simple issues or complex system wide problems. Once a problem area is identified, you drill down to its root cause by asking “Why?” five times.

Five Why’s in Action

Let’s take a simple example and run it through this method.  This is an actual problem that occurred when I was a Director of Nursing (DON) at a skilled nursing facility, so I remember it fondly.

Problem Area: Our customer satisfaction responses indicated a concern with beds not being made until afternoon. We completed a linen inventory and had plenty of linen to be able to get them made on time. We pulled together the team of CNA’s and laundry staff and here’s how it went.

#1:   Why aren’t the beds made until the afternoon?

Staff Response:  We have a lot of linen changes and don’t have enough linen available to make all the beds until then.

#2:  Why don’t you have any linen?

Staff response: Because all the linen is back in laundry waiting to be washed and it’s not ready until 11am. We’re serving lunch starting at 11:30am, so we can’t get to it until afternoon.

#3: Why is the linen not ready until 11am?

Staff response: Because the evening laundry staff leave at 7pm and no laundry is washed during the night, so we run out, and night shift hoards linens for their use because they run low, too.

#4: Why doesn’t the morning staff get the laundry out first thing in the morning?

Staff response: The morning laundry staff don’t come in until 9am so it takes them a while to catch up.

#5: Why do we schedule these hours in the laundry?

Staff response:  These were just hours that we’ve always scheduled, and we’ve just kept it the same over the years.

Root Cause Analysis (RCA) Gets Results

Getting to the root cause can be fascinating! If I would have stopped at #1, I might have considered buying more laundry, but that would have been a waste of money since the process we had couldn’t keep up even with additional linens. Or worse, I might have read the night shift the riot act for hoarding linens. They were just trying to do their jobs.  Using this iterative exploratory method of the why’s behind the issues, we were able to identify a simple scheduling issue and a process change that could be easily adjusted to better meet the staff and residents’ needs.

Our solution was cost-free and saved me ordering more linens. We created dedicated carts for each shift to make sure the hoarding stopped.  We also explored why more linen changes were occurring and identified an increase in long-term residents with incontinence who were not candidates for retraining. This taught us that we also need to watch our acuity and adjust processes as our resident population changed.

So if your New Year’s Resolution isn’t working out for you, it’s not too late in the year to elect a new one.  Consider a new goal to simply ask more questions – five to be exact.