Steps to Quality Improvement > Planning

Identify the Problem and Its Causes

The first step in planning the intervention is to identify the problem. The QI team has gathered and analyzed data that reveal disparities in health care delivery or health outcomes, or gaps in the provision of CLAS.

Once a problem is identified, the team must determine its causes or contributing factors to identify changes that could solve or mitigate it. As illustrated below, any one or a combination of issues could contribute to a problem.
 

1. Possible Causes or Contributing Factors		Problem
Poor diet and lack of exercise for various social, cultural, economic and lifestyle reasons Patients do not understand the negative effects of overweight and obesity and how to combat the problem. Physicians are uncomfortable discussing the topic with patients. Physicians feel unprepared to discuss the topic with patients of different cultural or ethnic backgrounds.		A significant and increasing number of members in a health plan are overweight. Approximately 20% of children or adolescents are ≥95th percentile for BMI for their age. Latino children have significantly higher rates of BMI ≥95th percentile than other children.
2. Possible Causes or Contributing Factors		Problem
Physicians do not know whom to call or contact when they need an interpreter. Many physicians do not have equipment to comfortably use telephone interpreter services. Physicians are unhappy with the amount of time they have to wait after requesting an interpreter and are often put on hold for long periods of time when using telephone interpreters. Locally available in-person interpreter services are costly, and it is faster and easier to use a relative or friend to interpret.		The majority of physicians in a health care organization do not use interpreters when seeing patients with limited English proficiency.

To identify possible causes or factors contributing to the problem, the QI team may find answers in the assessment it conducted. If earlier assessments did not identify the specific causes of a problem, the team may want to collect more, or different, data.

L.A. Care Health Plan, a local public agency serving residents of Los Angeles County, California, recognized the impact that excessive weight was having on its members and began measuring the prevalence of overweight and obesity in selected members from 2001–2003.

The plan extracted more than 2,000 well-child and adolescent well-visit medical records. As in Example 1, data showed that approximately 20 percent of children and adolescents sampled met or exceeded the 95th percentile for BMI for their age. They also found that Latino children were more likely to be overweight or at risk for overweight than the overall sample.

As a part of its assessment, L.A. Care Health Plan surveyed practitioners about their training on treating obesity in their patients. More than 98 percent of the practitioners expressed interest in training on how to treat and prevent obesity. The QI team learned that practitioners feel unprepared to discuss such a sensitive topic with their patients and that they might benefit from training or from tools to use in their offices when addressing the topic with patients.

Other methods can also help organizations identify causes or contributing factors. The National Public Health Performance Standards Program’s Users Guide11. Department of Health and Human Services National Public Health Performance Standards Program User’s Guide: Using performance standards to improve public health practice. Updated April 2006. Available at: http://www.cdc.gov/od/ocphp/nphpsp/Documents/NPHPSPuserguide.pdf October 5, 2007. suggests the following steps to determine a problem’s causes or contributing factors.

1. Brainstorm. Invite people familiar with the problem to develop a list of all possible causes, using the resources gathered to date—which includes the analysis performed during the assessment phase and the data.
2. Organize causes into similar categories, for example, people (e.g., personnel shortages, poor training, limited experience or expertise), methods (e.g., systematic barriers, slow response times, confusing protocols), information (e.g., lack of information about the causes of disparities, lack of awareness or education).
3. Visualize. Chart causes and effects. Graphic cause-and-effect representations can help people visualize the connection between problems and their potential causes. One example is a fishbone or cause-and-effect diagram.

A fishbone diagram can foster discussion during brainstorming and help sort ideas into useful categories. In this example, causes are listed under five categories.

1. Physician Encounter
2. Materials
3. Limited English Proficiency
4. Economic
5. Culture & Lifestyle

The QI team can use section names that best categorize the causes they identify. It can simply ask itself why a problem occurs and make the connection. Individual causes can branch off major categories in clusters or subcategories.