PURPOSE:
A Root Cause Analysis assists in the development of a quality improvement plan for specific areas of service delivery.
WHAT IS A ROOT CAUSE?
- Root causes are underlying causes.
- Root causes are those that can reasonably be identified.
- Root causes are those management has control to fix.
- Root causes are those for which effective recommendations for preventing recurrences can be generated.
Root causes are underlying causes. The goal should be to identify specific underlying causes. The more specific the team can be about why an event occurred, the easier it will be to arrive at recommendations that will prevent recurrence.
Root causes are those that can reasonably be identified. Occurrence investigations must be cost beneficial. It is not practical to keep valuable staff members occupied indefinitely searching for the root causes of occurrences.
Structured Root Cause Analysis (RCA) helps the team get the most out of the time they have invested in the investigation.
Root causes are those over which management has control. The team should avoid using general cause classifications such as operator error, equipment failure or external factor. Such causes are not specific enough to allow management to make effective changes. Management needs to know exactly why a failure occurred before action can be taken to prevent recurrence. We must also identify a root cause that management can influence. For example, identifying “severe weather” as the root cause of medications not being delivered on time to the consumer is not appropriate. Severe weather is not controlled by management.
Root causes are those for which effective recommendations can be generated. Recommendations should directly address the root causes identified during the investigation. If the team arrives at vague recommendations such as, “Improve adherence to written policies and procedures,” then they probably have not found a basic and specific enough cause and need to expend more effort in
the analysis process.