New York State Department of Health Shares QI Approach for Solving Childcare Inspection Problem

June 20, 2018|8:25 a.m.| ASTHO’s Performance Improvement, Research, and Evaluation Team

A culture of continuous quality improvement (QI) is considered the gold standard that many health departments seek to achieve. By improving overall performance and quality, health departments can become more effective and efficient, cut costs, and get better results for the communities they serve. The New York State Department of Health (NYSDOH) is well on its way to creating such a culture. Half of the department’s employees—nearly 2,250 individuals—have received QI training and the other half plan to do so within the next year. While the agency utilizes several QI approaches and tools, including Plan-Do-Study-Act and Lean, there are two tools they use consistently: fishbone diagrams and the five whys method.

ASTHO spoke with NYSDOH’s Robert Schmidt, director of strategic planning and performance improvement, and Isaac Michaels, the agency’s health program coordinator, about how the department uses fishbone diagrams and the five whys method to identify the root causes of programmatic, operational, and administrative problems and to promote continuous QI.

How does NYSDOH use fishbone diagrams and the five whys method?

Translating this to public health, NYSDOH regularly uses these two tools to identify the cause of programmatic, operational, and administrative issues as a part of its QI methodology. In 2014, NYSDOH collaborated with the New York State Office of Children and Family Services (NYSOCFS), the office charged with ensuring the health and safety of children within childcare facilities, to utilize the five whys method to better understand why licensors weren’t performing quarterly inspections of approximately 1,800 (30%) childcare facilities. These agencies felt it was critical to identify the cause of the problem because federal law mandates that states have health and safety requirements in three areas: (1) infectious disease prevention and control, (2) safety of the building and physical premises, and (3) minimum health and safety training appropriate to the provider setting. To identify the cause of the problem and ensure compliance with the law, the agencies first used a fishbone diagram to group possible causes into categories. They examined the process, environment, materials, information, people, systems, and equipment, and identified issues within the process for both scheduling and performing childcare facility inspections.

Digging deeper into why licensors were not scheduling these inspections, the agencies identified “other priorities” as the cause of the problem. However, using the five whys method, the agency determined that the root cause pointed to office personnel lacking the authority to assign and delegate tasks to administrative staff, as illustrated in Figure 1. To address this hurdle, NYSDOH and NYSOCFS clearly defined tasks and duties for administrative support staff, which allowed their licensors to spend more time in the field.

Similarly, they used the five whys method to determine why licensors weren’t performing scheduled inspections. The agencies concluded that a main factor was licensors not being able to enter the facilities. When they asked themselves “Why?” once more, they found the root cause to be the sites’ operating hours, with several closed during normal business hours. To address this problem, the agency developed a policy that providers should notify NYSOCFS when the facility is closed during certain hours. This policy ensures that the licensors can plan inspection visits at times when they can enter each facility. By addressing these two problems, among other minor issues identified through the five whys method, NYSDOH and NYSOCFS anticipate completing 100 percent of their required quarterly inspections moving forward.

NYSDOH Five Whys Method

Figure 1: Example of the New York State Office of Children and Family Services’ use of the five whys method to conduct a root cause analysis on childcare facility inspections not being scheduled.

What are the benefits of using these tools?

Fishbone diagrams and the five whys method are two tools that can be used alone or in combination with other QI tools such as Lean, Six Sigma and Kaizen. Both tools can be used to solve a multitude of problems by identifying the true reason for a barrier or issue. Unlike some other QI tools, they are not time intensive to conduct and do not require statistical analysis. According to NYSDOH staff, “success comes from how well you find the root cause.”

Learn how other state and local public health departments use fishbone diagrams and the five whys method to promote continuous QI and determine the root causes of programmatic and administrative problems:


This work was supported by funds made available from the CDC’s Center for State, Tribal, Local and Territorial Support (proposed). The content, findings, and conclusions shared are those of the authors and do not necessarily reflect the official position of or endorsement by the CDC.

ASTHO is dedicated to increasing state health agency capacity to improve the performance and quality of the public health system. ASTHO does this by providing technical assistance and resources to states in the areas of accreditation preparation, national performance standards assessment, and quality improvement. Contact accreditation@astho.org for more information.

Jamie Ishcomer, senior analyst of quality improvement and performance management at ASTHO, contributed to this article.