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Two Tools for Addressing Challenges at Your Medical Practice


Things will go wrong in your practice. It’s a given. What’s important is what you do when they go wrong.

Let’s face it: Failure is a much more effective teacher than success.

There is something about the sting of a plan gone wrong that helps to enhance our self-awareness and make the lessons we learn stick with us. So, how do we maximize these learning opportunities in our practice? When something goes wrong, how do we make sure it doesn’t happen again?

Oftentimes, practice leaders will take a quick solution that on the surface resonates with them and feels like the right problem to tackle, but are their techniques that can assist us to get to the root of the problem?

Of course; here are two.

Five Whys
This is the simplest technique, but it is very effective.

When faced with a challenge in your practice, you simply ask and answer the question, “why,” five times. By the time you’ve reached the fifth response to that question, you’ve likely reached the root cause of the problem.

Here’s an example: You receive a letter from a long-time patient telling you that your office can’t get their billing straight and they’ve had enough and they’re going to switch their care to another practice. Gather your staff around and ask the first level question of why. “Why did her billing get wrong?” You find from that question that she’s on an unusual private-payer insurance that isn’t set up in your billing system and the billing team is handling manually. You ask, “Why aren’t they setup in the billing system?” You discover that billing hasn’t had the time to get them setup with the software provider. “Why don’t we have the time we need to do this?” This question leads to the response that the billing team is working 70 hours a week right now catching up on collections from a different, much larger insurance provider. “Why do we have so much in collections there?” You discover then that the larger insurance company recently changed their billing system and the billing team has to make many manual updates/corrections each day because they haven’t been trained on the new system. When asked why they aren’t trained on the new system, the response is that they haven’t been able to commit the time to attend the sessions.

You continue this line of questioning until you reach what sounds like a root cause of the problem. In this case, what seemed like a simple problem initially of not having a small payer set up in your billing system turns out to be caused by a much larger problem of not sending the billing team to the training sessions they need for a much larger private-payer. Sometimes you can get to the root cause by asking the question, “why?” just a few times. With other situations it will take four, five or even six levels of questioning to address the root cause. However long it takes, the important element here is to continue to probe into why something is going wrong.

Fishbone Diagram (or Ishikawa diagram)
This technique comes from Dr. Kaoru Ishikawa in the quality movement and is often also referred to as a cause-and-effect diagram. This technique is broken into three parts: brainstorming, prioritizing, and action planning.

The first step is to identify a problem statement that you’re challenged with. Once you have the problem defined that you want to address, gather your team together and start to brainstorm potential causes broken into five different categories: man, material, machine, method, and measurement. It is called a fishbone diagram because of the way it will look when these potential causes are visually mapped out.


Machine refers to equipment or technology that you are using at your practice. What kinds of breakdowns or issues related to your equipment could be causing your underlying problem? Man is related to the people part of your practice. What kinds of issues could your staff have introduced into the problem that might be the cause? Material has to do with supplies and supporting materials that are necessary to conduct your practice. Think here of everything from medical supplies to office supplies to toiletries for the lobby bathroom. What kind of impact could these materials have on your problem? Method is all about the processes, procedures, and protocols you are using in your practice. Lastly, measurement looks at the metrics you’re using and the data that feeds those metrics - Are they reliable? Are they accurate? Are they measuring the right factors?

Once your team has brainstormed an adequate number of possible causes within each category, it’s time to prioritize them. Use a team polling approach to determine the top three most likely causes across all these potential areas then set up action plans against each of those three items.

Things will go wrong in your practice. It’s a given. What’s important is what you do when they go wrong. By finding the underlying causes, you’ll make your practice more successful. Getting your team involved in the process of solving problems is a great approach to building team morale as well. Try these tools this week - see if they help you get to the root of challenges at your practice.

Find out more about George Taylor and our other Practice Notes bloggers.

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