1. Identify the problem
2. Identify the cause or causes
3. Come up with solutions involve team
4. Develop a plan. Back to our example above, not only is the inventory list done by one nurse, it is crosschecked by a second nurse. This way, nothing is missed.
5. Implement the plan. In our example above, the plan was implemented right away.
6. Monitor the progress.

Please refer to the book for more details on this activity.