The Quality Improvement Team at your local hospital is investigating the case of Mr. Baum, who was recently admitted for respiratory difficulties but experienced other health problems while undergoing treatment. The goal of the team is to identify errors and systems issues/failures that affected and prolonged Mr. Baum’s hospitalization. The team will then suggest process improvements that will reduce the likelihood that these errors/failures will happen again in the future.

1. Read “The Case of Mr. Baum (PDF).”
2. Cre ate a fishbone diagram of this case for the Quality Improvement Team. You may download and use the Fishbone Template (Word).
3. Identify process improvements that could reduce the likelihood that these errors/failures will recur in the future.