Every statistician knows that basing a decision on limited data is certain to generate problems. Non-statisticians, however, may find making a decision without any data a bad habit to break. “Point mentality” – responding immediately to data that seems to indicate a change but may just be a reflection of natural variation – is even more endemic to daily decision making. The recurring question is: How can outcomes be evaluated when there are multiple options involved, including ones that no one has anticipated?

Enter the humble affinity diagram.

Affinity exercises, named for the ways in which ideas tend to group themselves together, are valuable tools when issues or problems seem complex or difficult to understand. An affinity diagram offers a way to organize output from brainstorming. They can sort out uncertain, disorganized or overwhelming observations about a process, and they inspire participation and support from a group, rather than applying a solution handed down from higher levels of management.

Example: Problem with Prescription Delivery

A West Coast hospital system was wrestling with a problem of prescriptions either being delivered to patients late or so slowly that discharge orders were delayed. Those close to the process were blaming each other (“It’s the pharmacy’s fault,” “Doctors don’t send scripts down early enough,” “Prescriptions pile up at nurses’ stations,” etc.). It was time to call in some team skills and the first of these was the affinity exercise. Procedures for approaching a problem with affinity exercises are:

• Assign a group leader.
• Agree on a statement of an issue or problem, often framed as a question (Theirs was “What are the barriers to on-time delivery of medications?”).
• Brainstorm responses to the question or problem. This can be done by using the Crawford slip method, where members of a group write down ideas – one idea per 3″ x 5″ card or sticky note (preferable) – in silence rather than discussion.
• Ask participants to post their cards or sticky notes, identifying similar ideas and grouping these in affinity with each other.
• After all ideas have been posted and grouped, label each group of ideas with a header that identifies a general topic.
• Ask group members to walk around and look at the notes that have been posted. This exercise provides an opportunity to clarify ideas and opens the door to discussion.²

The problem has not been solved at this point, but the affinity diagram helps participants identify issues that lay the groundwork for considering options for improvement.

The following case studies illustrate how helpful an affinity diagram can be.

The brainstorming/Crawford slip approach yielded the following observations:

• Pharmacist can’t read the order
• Procedure is unclear
• Prescription requests sent by phone
• Quantity is often wrong
• Pharmacists aren’t familiar with medications
• New staff in pharmacy
• Uneven workload
• Late mornings are extremely busy
• Changes in medication orders
• Inventory not recorded properly
• Labels can’t be read
• Lack of training
• Delivery schedules are unpredictable
• Orders aren’t signed properly
• Shortages of containers for certain meds
• Blanks on the form are too small
• Medication stop orders aren’t clear
• Unevenness in staff schedules
• Shift changes delay delivery
• Information isn’t correct
• Patient’s name not clear

The information was organized by related topics (those that have affinity with one another), generating the following categories and topics.

Environment and Materials

• Late mornings are extremely busy
• Shortages of containers for certain meds
• Inventory records missing
• Delivery schedules unpredictable

Orders

• Pharmacist can’t read the order
• Labels can’t be read
• Blanks on the form are too small
• Patient’s name not clear
• Prescription requests sent by phone

Staffing Issues

• Pharmacists aren’t familiar with medications
• New staff in pharmacy
• Workload uneven
• Lack of training
• Unevenness in staff schedules
• Shift changes delay delivery

Accuracy

• Medication stop orders aren’t clear
• Procedure is unclear
• Quantity is often wrong
• Changes in medication orders
• Orders aren’t signed properly
• Information records missing

A graphic display of the groupings would fit into the template shown below.

The categorized topics do not solve the problem of slow delivery of medications. They do, however, point the way to improvement by addressing one area in a systematic way and provide visual information about the issues raised. At this point, other tools will become useful in the interest of addressing the problem of slow delivery. Data must be collected in a timely and consistent way, and at that point, control charts may be appropriately generated, identifying trends in the delivery process.

Example: Values That Represent a School

Affinity diagrams are useful in organizing disparate information of any kind. Students at The Miami Valley School in Dayton, Ohio, were asked to identify values that represented their experience at the school by listing qualities that they saw in the ideal student. Generating hundreds of ideas meant that boiling the qualities down into core values that represented the school was a Herculean task. Affinity diagrams helped to organize this list. Among the very long list were the following traits:

• Perseverance
• Happiness
• Integrity
• Intelligence
• Broad interests
• Service
• Engagement
• Tenacity
• Stick-to-it-iveness
• Respect for others
• Tolerance
• Comfort with ambiguity
• Politeness
• Courtesy
• Interest in others
• Positive relationships
• Kindness
• Helpfulness
• Values
• Belief in self
• Respect for teachers
• Diversity
• Ability to get along
• Broad range of interests
• Helpful
• Unselfish
• Knowledge of self
• Responsiveness
• Love of life
• Honesty
• Diligence
• Hard working

These were organized in the following way and placed on the template. Titles that a representative group of student determined were inserted as headers.

Integrity

• Respect for others
• Honesty
• Belief in self
• Tolerance
• Responsiveness

Kindness

• Politeness
• Courtesy
• Helpful
• Unselfish
• Interest in others
• Helpfulness
• Respect for teachers
• Ability to get along

Grit

• Diligence
• Perseverance
• Tenacity
• Stick-to-it-iveness
• Hard-working

Celebration

• Happiness
• Intelligence
• Broad interests
• Service
• Positive relationships
• Values
• Knowledge of self
• Love of life
• Diversity
• Engagement

The “problem” that the students and school community solved was their need to articulate core values that reflected the temperament of the school and the qualities that they determined to be representative of the students themselves. This involved different kinds of thinking from that of the hospital above, where a genuine problem was crying out for solution. In the school example, the affinity exercise offered an opportunity for students, teachers and parents to reflect on what values were important to them. The affinity diagram is a flexible tool that can respond to different needs.

Reference

Cleary, Barbara. “Quality in Healthcare; Affinity Diagram Example.” http://www.internetworldstats.com/stats.htm