Problems and solutions of real cause verification in hospital quality control cycle of China
Review Article

Problems and solutions of real cause verification in hospital quality control cycle of China

Tingfang Liu, Dan Zhang, Junyang Gao

Institute for Hospital Management of Tsinghua University, Tsinghua University, Beijing 100084, China

Contributions: (I) Conception and design: T Liu; (II) Administrative support: T Liu; (III) Provision of study materials or patients: D Zhang; (IV) Collection and assembly of data: J Gao, D Zhang; (V) Data analysis and interpretation: J Gao; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Tingfang Liu. Senior Adviser of Dean of Institute for Hospital Management of Tsinghua University, Professor, Graduate Student Supervisor, Tsinghua University, Beijing 100084, China. Email:

Abstract: Real cause verification is key to quality control circle (QCC), determining the ultimate effectiveness of hospital QCC activities. By studying cases from China Federation for Hospital Quality Control Circle, this paper analyzes problems of real cause verification in hospital QCC of China and proposes normalizing QCC training, establishing quality circles open mode for improvement.

Keywords: Quality control cycle (QCC); real cause verification; characteristic diagram; tally sheet

Received: 29 August 2016; Accepted: 06 September 2016; Published: 15 November 2016.

doi: 10.21037/jrh.2016.09.05

At present, the quality of medical service in China is difficult to meet the needs of the masses. As a result, the contradiction between doctors and patients is acute. Leaders of many hospitals have recognized the importance of hospital management and quality improvement, and have introduced the hospital management tools to carry out the continuous quality improvement activities. In recent years, quality control circle (QCC) as a quality management tool, has been widely applied in hospital. I searched Chinese Academic Network Publishing Database of CNKI in the field of medical and health science and technology with the theme of QCC. The amount of the literature obtained is shown in Figure 1 (the deadline to May 10, 2015). As we can see, pertinent literature has been increasing exponentially since 2011.

Figure 1 Changes of the number of literature related to QCC in CAJD of CNKI. QCC, quality control cycle.

QCC is quite different from traditional management tools. Through a bottom-up approach and by mobilizing every medical staff, management will permeate every department, every process and every link (1). It transforms traditional empiric management and extensive management into scientific management and fine management. Hospital management will shift from traditional qualitative management to quantitative-based management combining quantitative and qualitative analysis. QCC contributes to the formation of long-term mechanism of continuous improvement of quality (1,2).

Real cause verification is the key part of QCC because whether the real cause can be parsed out is related to the overall success of QCC activities. Cause analysis of QCC usually requires a comprehensive analysis of the possible causes of the problem by brainstorming, then members determine which of these causes are main causes by the method of voting. Finally, we need real cause verification to determine the real causes. This paper, on the basis of cases study and literature analysis on real cause analysis of hospital QCC, summarizes the main problems and tries to give countermeasures and suggestions.

Materials and methods

The sample cases of this article come from the case library of China Federation for Hospital Quality Control Circle which was sponsored by Institute for Hospital Management of Tsinghua University. The case library consists of entries of the First and Second national Quality Control Cycle Competition of Chinese Hospitals and cases before the two competitions. There are 396 cases altogether, of which 39 cases are cases before the two competitions, 96 cases are from the first competition and 261 cases are from the second QCC competition. By studying the cases and statistical analysis, this paper analyzes problems of real cause verification in hospital QCC of China.

Problems of real cause verification in hospital QCC

The use of characteristic diagram is non-standard

In QCC cases studied, almost all cases adopt characteristic diagram to analyze causes. Characteristic diagram, also called fishbone diagram or Ishikawa diagram, is an approach of finding out causes based on results (3). Through all staff participation and brainstorming, real causes will be found out and the relationship between the cause and effect will be shown in the form of chart (3,4). In terms of solving problems and improvement, characteristic diagram is considered to be one of the most convenient, quick and effective method. Therefore, it is widely applied in QCC (5). Big, medium and small bones of characteristic diagram represent macro, meso and micro causes respectively. When analyzing macro causes, the following five aspects should be considered: man, machine, material, method and environment. For simplicity, we can call them 4M1E for short (3).

However, in 33.59% of cases, characteristic diagram is non-standard. De-normalization is mainly embodied in the following three questions.

The analysis don’t focus on focal points for improvement

Ten steps and seven tools of QCC are interrelated, intertwined and gradually deepening. In the step of grasping the situation, we find out focal points for improvement, without which improvement activities will be unfocused. Thus cause analysis should focus on focal points for improvement, which can reduce unnecessary workload and avoid a “Comprehensive” but useless analysis. Otherwise, it may result in less effective or even come to naught. The process from causes to main causes then to real causes is a process gradually narrowing down to seize the focal points. Grasping the progressive relationship between steps of QCC will play a multiplier effect.

In some cases studied, cause analysis doesn’t focus on focal points for improvement even though the focal points for improvement have been found out. Take for example a QCC of a first-class hospital at grade 3 with the theme “decreasing no positioning rate of ostomy pre-operation”. Members of QCC drew Plato diagram after using tally sheet to check the fact and found focal points for improved as follows: insufficient medical cooperation, the nurse’s lack of knowledge of positioning, no procedure of positioning and lack of positioning tools. Plato diagram is shown in Figure 2.

Figure 2 Plato diagram of the QCC taken for example. QCC, quality control cycle.

However, when using characteristic diagram to analyze causes, they didn’t focus on focal points for improvement. Instead, they analyzed the causes of “no positioning of ostomy pre-operation”, shown in Figure 3.

Figure 3 Characteristic diagram of the QCC taken for example. QCC, quality control cycle.

Analysis of macro causes of characteristic diagram is non-standard

Generally speaking, when analyzing macro causes, the following five aspects should be considered: man, machine, material, method and environment. It will be systematical and integrated to analyze macro causes of problems in according with these five aspects, i.e., 4M1E. Of course, if causes of a problem are not related to some aspect, instruments for example, this unrelated aspect can be removed. “Others” is considered to be one of the macro causes in a few cases, which shows a lack of clear direction when analyzing the problems and is prone to result in an incomplete and incomprehensive analysis of the situation.

Incomplete analysis of meso and micro causes of characteristic diagram

Cause analysis of QCC needs a full discussion until the root causes are found In the process of grasping the situation of some cases, items of tally sheet are macro causes of the problem. Then focal points for improvement will be found out using tally sheet. However, the thinking is limited in this framework and it fails to conduct a thorough analysis of meso and micro causes.

Lack of real cause verification or de-normalization of real cause verification

QCC is considered as a scientific tool because it’s a combination of qualitative and quantitative analysis, making up the disadvantage of traditional management based on experience. Cause analysis of QCC usually requires a comprehensive analysis of the possible causes of the problem by brainstorming, then members determine which of these causes are main causes by the method of voting. However, it contains too many subjective judgments by the method of voting. The key causes selected by voting may not be real causes if they have not been verified by the data collected on site. The causes that have been verified by the data collected on site are real causes. If we begin to develop and implement countermeasures without real cause verification, countermeasures may have little or no effect at all, resulting in a waste of manpower and resources. Of all the cases studied, 58.84% cases lack real cause verification. Even in the cases that do have real cause verification, real cause verification is non-standard, making up 23.93% of cases having real cause verification. De-normalization of real cause verification is mainly embodied in verifying real causes through voting, scoring and literature review. The fact is that real cause verification must comply with the principle of “three now”, which means we must use data collected on site to verify.

Design of tally sheet is non-standard

Tally sheet is a table designed to collect data. It is used to record and statistical analysis of facts. Quality management emphasizes on the fact. Tally sheet must be designed in order to grasp the fact. Therefore, tally sheet is really an essential part of grasping the situation and real cause verification. So it’s important for tally sheet to be standard, systemic and integrated. The design of tally sheet should include all the steps across the process, from the beginning to the end and truly reflect every relevant factor. We will not be able to verify real causes if the complete process cannot be restored. Tally sheet should be designed according to the principle of “three now”, namely the scene, now things and reality. However, by analysis of the cases, it is found that design of tally sheet is non-standard, which mainly embodies ambiguousness of items of tally sheet. It requires that each individual has a unified and determined awareness of every item of tally sheet if we want to make sure what we record using tally sheet is fact. For example, in some cases, tally sheet is designed to check causes of a problem. One of the items of tally sheet is “nurses’ lack of responsibility”. The concept of lack of responsibility is vague and different nurses may have different understandings. Thus it is difficult to ensure the result of tally sheet is in accordance with the fact.

Tally sheet is the key tool of real cause analysis. The design of tally sheet requires tracing the process on site and participation of staff who take part in the process. The content of tally sheet can be summarized as: what to check, why to check, who to check, when to check, where to check, how to check and how much to check. Among them, items of tally sheet, i.e., what to check, are very important. Instead of ambiguous items, items of tally sheet must reflect the fact. After tally sheet is designed, it should be put into use and modified according to feedback before it is finally completed.

Countermeasures and recommendations

Standardizing the training of QCC

Currently the training of QCC is not widely spread because there are few authoritative training institutions and personnel. Most hospitals mimic QCC activities after a simple study tour. Members of QCC don’t master the principles and tools of QCC. Therefore, in the early stage of QCC promotion, we need authoritative institutions to give standardized training and even on-site demonstrations to staff of hospitals in accordance to standardized textbooks.

Establishing open model of QCC

With popularity of the theory and operating practices of QCC, the concept of QCC needs for further change. QCC should transform from a closed model to an open-model. QCCs of hospital are more complex than that of industry, because the QCCs of hospital involve human security, which is reason why I propose the open model to introduce the mechanism of outside participation. There are two kinds of mechanisms of outside participation. One is that personnel of the same department provide advices to members of QCC and the other is that experienced professionals or chiefs of departments provide guidance for QCC. Personnel of the same department have a relatively rich experience in practical operation and may also have unique insights into the issues. What’s more, the strategies for improvement formulated by QCC will be promoted across the department. Therefore, seeking their advices during the stages of cause analysis and voting for key causes is not only conducive to collective wisdom and solicit opinions, but also conducive to the outcome of the post-promotion activities. Since the members of QCC are mainly consisted of grassroots personnel who have little experience in QCC, it is necessary to consult experienced professionals or chiefs of departments to enhance the outcome of QCC. The schematic diagram of open model of QCC is shown in Figure 4.

Figure 4 The schematic diagram of open model of QCC. QCC, quality control cycle.

It should be stressed that not every QCC requires the involvement of outsiders. It depends on circumstances. Another step forward makes truth a fallacy. It is degree that should paid attention to of outside participation. Under the premise of the basic principles of QCC, select appropriate personnel outside QCC and participate moderately to maintain autonomy, democracy and independence of QCC, avoiding from one extreme to another.




Conflicts of Interest: The authors have no conflicts of interest to declare.


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doi: 10.21037/jrh.2016.09.05
Cite this article as: Liu T, Zhang D, Gao J. Problems and solutions of real cause verification in hospital quality control cycle of China. J Res Hosp 2016;1:22.


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