Fixing supply chain problems by asking 'Where else?'

A method to finding the root causes of inefficiency

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Pharma logistics can be a difficult business. Consider this technique from John W. Moran, as explained to PEX Network...

In any industry, it is tempting to attack symptoms without addressing underlying causes — but to do so is to commit yourself to endless fire fighting.

Yet the symptoms are telling us something: they are an indication of something that has occurred, either good or bad. In quality improvement we are encouraged to quickly find the root cause of the symptom and not spend time analyzing it since the symptom, while superficially troubling, is not the problem so much as a red flag we should be grateful we can see: put off solving a root cause, and you'll only spread the damage further - and it might be fatal to the organisation as a whole. 

Once a symptom is identified, you need to start asking: where else does this occur?

From experience I have learned that a thorough analysis of a symptom that is causing problems often leads to other areas that may be experiencing similar issues and this expands the potential solution space. Once a symptom is identified, you need to start asking: where else does this occur?

A problem I encountered in the past as a hospital administrator in an orthopedic hospital was patient falls. The first analysis of the symptom indicated it was in the hospital room but as we asked the question 'Where Else' it could occur we uncovered a number of areas that needed to be addressed.

Symptom: Patient falls in the hospital


Below are a few examples of Where Else:

• Where else? In their hospital room – getting out of bed, going to the bathroom, or getting into a chair.

• Where else? In the corridor during walking exercises - While Ambulating

• Where else? In the physical therapy room during therapy

• Where else? Radiology – getting in position for a scan

• Where else? At the hospital entrance being discharged to their ride home

• Where else? At home after surgery

This expands the solution space since a fix in one area still would result in additional patient falls and injury in the other areas if they are not addressed. As each one of these 'Where Else' areas was analyzed they lead to improvement and cost reduction opportunities.

Once the 'Where Else' areas are identified you want to analyze each one by asking the following questions as shown in the matrix below:

• When does it happen? – specific time of day

• Why does it happen? - causes

• How to correct it? – quick solutions

• What is the cost of the correction? – investment required

• What is the priority? – (High, Medium, or Low)

The fixes that were put in place in the Where Else areas:

• Hospital room – all equipment needed for a patient to use when they got home (reachers, sock aid, long handle shoe horn, elastic laces, and long handle sponge) were labeled with the room number so they would not migrate to other rooms or be taken home by the patient. Potential patients were given a list of items they needed to buy beforehand to use in the hospital and when they got home. The lobby gift shop had packages prepared with all the needed items as well as a list of other stores where they could be purchased. This had a positive revenue impact to the gift shop of $25,000 per year.

Depending on the physical size of the patient, a policy was put in place to make sure the nurse or physical therapist could get the person up or additional help was available to minimize the risk of a fall.

In addition, patients, once scheduled for surgery, were given education about the procedure along with what items they would need to bring for their recovery therapy as well as what they would need at time of discharge.

• Corridor – before allowing a patient to walk in the corridor with assistance or alone the floor nurse would assess the person’s capability to do so. Hand rails were also installed on the corridors used the most by patients. The improvement team developed a comprehensive floor safety plan.

• Discharge - a large curb cut at the discharge area was made so the wheel chair could roll up closer to the car and make the transition to the car safer. Also it was noted that many patients took the pillows that were used in the wheel chair home since they needed extra padding. It was estimated that 10 pillows a day were taken home, costing the hospital approximately $100/per day. Significant cost savings were achieved by letting patients know before discharge to bring pillows as none would be provided at the time of discharge.

• At home – since this was out of the hospital’s control an orthopedic vendor was engaged that would go to the patient’s home and assess what would be needed to reduce the risk of falls in the house such as grab bars, toilet safety frame, tub chair, or transfer chair. If the patient purchased the needed items they would install them and train them on the use. In many cases it was covered by insurance.

Here's how the matrix above was used:


As an improvement team we figured out that just conducting patient fall assessments does not lead to a reduction in falls and we needed to actively manage and identify at risk patients from the doctor’s office through discharge to prevent falls. The Where Else technique helped us enlarge the solution space and not just focus on a single symptom.

This technique is applicable across businesses - you have to be aware of pain points. As a leader, you need to listen to the people who can tell you what's hurting, and your job is to take the information and turn it into a solution that can relieve the symptom for everyone - and not simply move the problem to where you can no longer see it.