Root cause analysis is a process used to systematically approach problem identification and analysis of an adverse event. The RCA process is useful in health care because it helps in getting to the real causal factors that lead to an adverse event or undesirable outcome, and provides insight into how an organization can proactively minimize future risks.

This article presents the basics of the process so that readers gain a greater appreciation of the value and benefit of an organized approach to problem identification and performance improvement, as well as the impact that processes in all areas of an organization have on each other.

Root cause analysis focuses on systems and processes, not individual performance. It allows for a critical look at processes in the clinical setting as well as those used throughout the organization that could affect the clinical processes. If a process is broken or needs improvement, then the problem will reoccur again and again.

The Division of Immigration Health Services began conducting RCAs more than three years ago. We have found that a variety of adverse events that result in undesirable outcomes are frequently related to just a few processes.

Ultimately, root cause analysis is about prevention—discovering the root causes so that steps can be taken to prevent a reoccurrence. Following are examples of some benefits of successful root cause analyses in the clinical setting:

• Earlier detection of depression and subsequently fewer suicide attempts and lengthy psychiatric hospitalizations

• Fewer instances of undetected medical conditions that escalate until they are out of control and result in increased suffering for the patient and great expense to the organization

• Fewer cases of active tuberculosis that go undetected until there is extensive exposure and increased cost and use of human resources.

Eight Steps
Organizations may have different approaches to root cause analyses. Below are the eight basic steps that DIHS uses in conducting RCAs.

• Identify the adverse event (undesirable outcome)
• Select the root cause analysis team
• Develop key points
• Identify the processes involved
• Identify the causes (within the processes)
• Develop risk reduction strategies (improvement measures)
• Implement risk reduction strategies (improvement measures)
• Measure the effectiveness of the risk reduction strategy

·    Identify the Adverse Event
In health care, adverse events are those that result or could result in undesirable outcomes. Such events are generally called sentinel events. They include things like unexpected deaths, suicides and homicides, actual or potential loss of limb or function, and allegations of abuse (sexual, physical or psychological).

·    Select the RCA team
The RCA team composition will vary depending upon the type of adverse event. It is important to include 1) people who are knowledgeable about the issues involved; 2) other stakeholders, those who may be somewhat removed but who could have influenced the event or could be impacted by it; and 3) people who have decision-making authority and can assure the implementation of improvement strategies.

For example, in a case where a patient had a serious adverse reaction after receiving the wrong medication, the RCA team would include, at a minimum, a medical doctor, a nurse and a pharmacist. In a correctional setting where security staff is frequently involved in the medication administration process, a representative from security might be appropriate for the team.

At times team membership may need to vary, as when participants are brought in for short periods because they have specific knowledge or information that is needed about the event, or because specific expertise is needed in developing a feasible risk reduction strategy. These changes in the team composition usually will be short term and for a specific purpose, as you will want to maintain the “core” RCA team.

·    Develop Key Points
The key points are determined by reviewing the data obtained from investigative reports, interviews and related documentation. Key points are then assigned to categories. This is a fundamental step in working toward a systematic approach. In health care the categories are defined based on important organizational functions or processes and may include information management, environmental management, leadership and human resource processes. The same functions and processes could also be identified as patient issues, environment, supplies and equipment, and people. A fishbone diagram is useful in organizing the categories.

·    Identify Processes Involved
Remember, processes are what we are after. Examples would be assessment, treatment, transfer, discharge, etc. The processes are then assigned “spines” on a fishbone diagram based on the related category. For example, a suicide attempt might be related to inadequate staffing. The category would be identified as “human resource” or “people.” The process would be scheduling of staff.

Flow charting is useful in analyzing the processes since it enables you to see how the processes should work as well as how they were actually performed. Walk through the steps. Determine what didn’t work and why. Ask questions. For example, was the problem a failure to follow the established process? Was the process followed but needs to be improved? Consider all possibilities. Ask “why” repeatedly. Frequently this will lead to identification of other processes that may have failed. Based on this analysis, determine what needs to be fixed. Each cause would be another spine extending from the relevant process on the fishbone diagram.

·    Identify Causes
Causes can be directly or indirectly related to the event. There can be—and usually are—several causes. The key element of a root cause analysis is repeatedly asking why until there are no more answers. When there are no more answers that could be the root cause, then identify where you need to improve. Keep in mind that sometimes you may never know the real cause or causes, but since the focus is on processes, the results will always lead to improvement.

·     Develop and Implement Strategies
After the processes that need to be fixed or improved have been identified, the next step is to develop and implement the risk reduction strategies (improvement measures). Remember to focus on the process and how it fits within the system, keeping in mind that several processes within a system may need to be fixed. You may have risk reduction strategies that are immediate, short term and long term. Make the strategies realistic.

·    Measure Strategy Effectiveness
The measurement strategy should be identified at the same time that you develop the risk reduction strategy. To do this, determine the results that you want. How will you know that the risk reduction has been effective, and what do you need to do to measure it? A common mistake is to monitor the implementation of the risk reduction strategies but not their effectiveness. Such strategies are improvements only if they make a difference. If they don’t, then try again ... before another adverse event occurs.

A Valuable Tool
Root cause analysis is not a magic bullet, but it is a valuable tool for evaluating causal factors after an undesirable event. The information can be used to identify problematic areas and to be proactive in preventing reoccurrences. With diligence, this approach will enable you to prevent “bad things” before they occur.