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Strategy Submission

Quality Improvement Project: Using Problem and Solution fishbone diagrams


Jeanette Koshar






Sonoma State University


Competency Categories:

Evidence-Based Practice, Quality Improvement

Learner Level(s):

Graduate Students, Pre-Licensure BSN, RN to BSN

Learner Setting(s):

Classroom, Clinical Setting

Strategy Type:

Online or Web-based Modules

Learning Objectives:


QI: Seek information about outcomes of care for populations served in care setting
QI: Appreciate the value of what individuals and teams can to do to improve care
EBP: Participate in structuring the work environment to facilitate integration of new evidence into standards of practice
Teamwork and Collaboration: Clarify roles and accountabilities under conditions of potential overlap in team member functioning


EBP: Initiate changes in approaches to care when new evidence warrants evaluation of other options for improving outcomes or decreasing adverse events
QI: Use a variety of sources of information to review outcomes of care and identify potential areas for improvement
QI: Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals

Strategy Overview:

  • I start out with this quote: Albert Einstein: "We can't solve problems by using the same kind of thinking we used when we created them."
  • I have used these fishbone diagrams for classroom discussions, didactic assignments and clinical assignments. They are effective in each setting.
  • I have used these as the basis of discussion/assignments related to these Adverse Events: The Lewis Blackman Story Video ( and First Do No Harm ( The post-licensure BSN students rated this as one of the most helpful assignments they had in an EBP/Research course.
  • Use both the problem and solution diagrams. The problem one is common and I developed the solution one to assist students in making evidence-based practice recommendations. They need to use both to make the connection between problems and solutions. I tried using just one as a stand-alone activity and it didn’t work.
  • Sources of evidence: Use of the diagrams emphasizes that EBP draws from nurse expertise, patient preference and the literature. Have them find and incorporate an EBP article pertinent to the solution.
  • Have students bold the items they assess as key to the problem and the solution. This helps students prioritize causes and identify a key solution.

Submitted Materials:

Additional Materials:

File format: Here is a website for the QSEN Quality Improvement Project Fishbone problem and solution assignment: They are set up similarly in each course. You will also find a link to well-done QI problem and solution fishbone diagram examples. Feel free to use all or any part of this information and just cite us as the source.

Evaluation Description:

Here is the evaluation rubric I developed


Quality Improvement Grading Criteria


Completes the Fishbone Problem and Solution Diagrams. Clearly states the problem and solution. Bold the item(s) (i.e. under people, equipment) that you assess as being key to the problem and solution.


Includes at least one item in each of the six categories (i.e. People, Processes, etc).


Uses the 6 areas of competencies: Patient Centered Care, Teamwork and Collaboration, Evidence-Based Practice, Quality Improvement, Safety and Informatics.


Evidence: uses each of the 3 sources of evidence (patient preference, nurse expertise, the literature)


Cites at least one EBP article in the solution diagram. Briefly explain how it informs your solution.


Is succinct


Clinical Presentation




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