Using a Fishbone Diagram to Assess and Remedy Barriers to Utilization of a New Registered Nurse (RN) Role in a Federally Qualified Health Center (FQHC)

Background: Increasingly, registered nurses (RNs) are incorporated into primary care teams. Yet there is wide variability in nursing roles and responsibilities across organizations. Policy makers and federal agencies (i.e. Health Resources and Services Administration [HRSA]) are urging in-depth examination of RN utilization in primary care. Currently, limited research exists that describes how primary care agencies learn to incorporate RNs into their care teams. Our 4-year HRSA–funded project seeks to enhance the use of RNs in primary care to the full scope of their licensure. The purpose/learning outcome for this presentation is to describe how the use of a fishbone diagramming process has begun to identify the root causes of limited utilization of a new RN role to advance the goals of one federally qualified health center (FQHC).

Methods: A quality improvement project is being conducted to assist a FQHC to enhance the practice scope of a new RN recently added to the primary care team. Led by the grant team, clinical team members utilized a fishbone diagram methodology (a.k.a., a cause-and-effect diagram) as the initial step to diagram the root causes behind the underutilization of the new RN. This exercise can help a team identify the most significant factors that influence the key factors limiting the use of the RN. By naming these potential root causes, the team and FQHC staff can be better poised to focus its efforts on the areas that will provide the greatest leverage for change.

Results: Preliminary data from the fishbone diagram process will be provided. Initial brainstorming with key informants suggests that the FQHC faces several barriers to actualizing the use of a RN to the full scope of her license. The barriers fall into four major categories: leadership knowledge/”buy-in,” finances, space, and clinic staffing. Regarding “buy-in”: the leadership at this FQHC actively aims to enhance its quality measures and its primary care medical home (PCMH) status, yet may not see the link between the use of a RN and these goals. Regarding finances, the administrative leadership describes these as a reason to limit the use of the RN. On space limitations, the staff describe this as an impediment to incorporating RN chronic care and transition management, and RN patient education in the clinic. The nursing leadership is aware of the benefits of an RN, but the clinic team is unaware of best practices within the RN scope of licensure to achieve staff, clinic and leadership goals.

Conclusions: As healthcare organizations seek to provide value-based care, full knowledge of the essential role of the RN in quality improvement and team-based care delivery is vital. The fishbone diagram exercise allowed this vital FQHC’s team members to identify the root causes around the problem of underutilization of the RN. It also helped the team to identify and launch RN role and team workflow changes.