You probably know there’s a problem you want to address in your community. There might be a high incidence of hypertension in a population group or not enough new mothers are using WIC. A community needs assessment or other sources might have helped you identify a problem that your health center, facility or program can support.
You might suspect a community health worker (CHW) program might help you solve this issue based on what you’ve read here or from one of the other programs that are popping up across the country.
Before you jump into starting a new CHW program, you need to get to the root cause of the issue. That kind of analysis will help you drill down past indicators to the reason why the problem you identified exists. Once you’ve identified some possible root causes, then you can move on to a more careful needs analysis.
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FInding the Root Causes of Your Community’s Health Problems
Community health problems can be complicated. But getting to the root cause doesn’t have to be. In fact, you can borrow a technique that any toddler knows: keep asking why.
The Five Whys (described in this document from CMS) is a problem-solving technique that is used to analyze the underlying reason for a problem. Five is a good rule of thumb, but you might technically need a couple more or fewer questions before you find the issue related to the problem.
History of the Five Whys
The Five Whys is one method out of several that fall under the concept of continuous improvement — also known as Kaizen. Kaizen is a Japanese philosophy in which businesses strive to make small improvements often rather than big pushes sporadically. Kaizen became popular around and following WWII because the war efforts required that processes were as efficient as possible and everything was utilized to the best of its ability.
However, it was Sakichi Toyoda, inventor and father of the founder of Toyota, who invented The Five Whys in the 1930s. The Toyota Motor Corporation developed the Five Whys technique as a way to understand problems in its production process so they could be fixed.
Today, Toyota and thousands of other companies rely on the Five Whys and other Kaizen exercises to improve production, lower costs, and reduce waste at a large scale.
how to apply the Five Whys technique
The first step to conducting the Five Whys is to gather a team of experts with differing views. For a community health program, you could meet with local leaders, community members, and perhaps representatives from local government or organizations. Once your team is complete, one person will be chosen as the 5 Whys Master — and they’ll moderate the activity, keeping participants focused and leading the conversation.
Next, the team you’ve gathered must come to an agreement on the definition of the issue. A clear, concise definition is crucial for moving ahead with the analysis. Otherwise, you risk coming up empty-handed with a broad problem that’s unlikely to be addressed.
Thirdly, it’s time to ask your five whys. You’ll want to substantiate the answers with data and evidence. Also, it’s worth noting that you may not hit a root cause within these 5 whys, so don’t rule out asking more than five times as long as the discussion is laser-focused on the issue you defined in step 2.
The fourth step is taking corrective action. Of course, in the case of community health initiatives, you can’t just walk out and heal people. But corrective action can include creating an educational plan, launching an outreach initiative, or partnering with local clinics for regular screenings. Once you’ve come up with the list of corrective steps, you’ll need to assign each step to a team member who’ll take ownership of it.
Finally, you’ll want to monitor progress and share the findings. It’s crucial to measure how your corrective action is (or isn’t) solving the problem. Only this way will you be able to measure whether you found the real root cause or need to go back to the drawing board.
How Toyota Uses the Five Whys Method
Here’s an example of how Toyota used the Five Whys to understand why its welding robot stopped working.
- “Why did the robot stop?”
The circuit has overloaded, causing a fuse to blow.
- “Why is the circuit overloaded?”
There was insufficient lubrication on the bearings, so they locked up.
- “Why was there insufficient lubrication on the bearings?”
The oil pump on the robot is not circulating sufficient oil.
- “Why is the pump not circulating sufficient oil?”
The pump intake is clogged with metal shavings.
- “Why is the intake clogged with metal shavings?”
Because there is no filter on the pump.
After the fifth question, it was clear to the engineers that they needed to put a filter on the pump. Problem solved.
How to Use the Five Whys for Community Health
Now have a look at an example of using the Five Whys in health education from AHRQ that could be addressed by a CHW initiative:
Problem: Recently, patients have stopped coming to the health education class.
- “Why do they say they’re not coming in?”
Patients forget to come or are not sure when classes are happening.
- “Why aren’t they getting reminders?”
Staff member who usually makes reminder calls to patients is not making the calls.
- “Why isn’t the staff member making calls?”
She does not have the list of patients to call.
- “Why doesn’t she have a list of patients to call?”
Current lists are not being created.
- “Why aren’t lists being created?”
The person assigned to create these lists from the electronic health record system is out on leave.
Now the root cause is clear! And the team assigned to asking the Five Whys can make some suggestions:
1. Assign an additional staff person to fill in and create reports when the person responsible is out.
2. Give the outreach caller direct access to the data and train her to generate her own up-to-date lists.
The above examples are simple, but the technique can be used with more complex problems too. Your community might need more women to receive breast cancer screening or community members don’t know how to access insurance benefits.
The next time you find yourself facing a problem and aren’t sure how to fix it, try asking, “Why?” a handful of times to see if you can find some clarity. When you feel like you’ve explored all the reasons behind an issue and you want to start a CHW program, you can move on to a needs assessment.
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