| Ishikawa fishbone diagram identifying all identified gaps contributing to inconsistent documentation and sharing of GOC across care settings. The problem statement (cause) is identified at the 'head' of the fishbone (far right). The major categories of causes of the problem are identified in dark blue: Education/Awareness, Environment/Culture, People, Conversation Workflow, Documentation, and Information Sharing. All identified causes are identified as branches from the appropriate category. GOC, goals of care; MRP, most responsible physician; ACP-GOC, Advanced Care Plan Goals of Care Discussion Record; EMR, electronic medical record; MOST, Medical Orders and Scope of Treatment; D/c, discharge