RCA Best Practices – Healthcare Administration

Using multi-disciplinary teams to conduct Root Cause Analysis leads to innovative solutions while simultaneously transforming group dynamics By: Denise G. Osborn, JD, MPH(2008)


What is Root Cause Analysis? Root Cause Analysis (RCA) is an effective tool that can be used to study why something that is undesirable has happened. A multi-disciplinary team works collaboratively to conduct a retroactive analysis by uncovering several contributory factors that led to the undesired event, as well as multiple root causes that actually caused the event. Each team member brings their unique perspective as to why the event occurred and what should be done to avoid a future re-occurrence. Structured brainstorming and robust interaction is encouraged by a team facilitator with the desired goal of helping the team to discover new and innovative solutions. The beauty of a well conducted RCA is revealed when everyone has contributed to the process and is able to see measurable results that led to positive change.


What do I need to conduct a thorough and credible Root Cause Analysis? A person to serve as a facilitator who is familiar with the RCA process; a multi-disciplinary team of eight or less persons; eight to 10 hours of scheduled time for four team meetings (time may vary depending upon complexity of the analysis); and access to and competency with word processing and flow charting software.


What are the components of a Root Cause Analysis?


  • A flow chart of the actual sequence of events that led up to the event.
  • A thorough literature review pertinent to the event being studied.
  • A flow chart of the optimal sequence of events that should have occurred.
  • A list of corrective actions that took place right after the event occurred.
  • A list of contributory factors (from brainstorming) that may have contributed to the event.
  • A drill down on each contributory factor by asking Why at least five times to find the root causes.
  • A prioritization of the root causes using a matrix, variables and scoring.
  • A list of proposed improvement actions with timelines for each root cause.
  • Mechanisms developed by the team to measure and report results such as bar graphs, scatter diagrams or run charts.


How does RCA transform group dynamics? A well-facilitated RCA not only provides an environment for learning but can also inspire positive cultural changes within an organization. Every RCA requires a thorough literature review before the first team meeting. This review contains important research including findings around what other organizations have done to address similar problems. This information takes the team above and beyond their own frame of reference and equips them to consider new approaches, best practices and methodologies. In essence, the RCA provides continuing education that may not have otherwise been introduced to the team members in their every day work. Similarly, team members are given an opportunity to learn more about what their colleagues do and how they approach problems. Exposure to other disciplines allows for a better understanding of the proverbial big picture and sensitizes people to the challenges that others face in performing their duties. The level of collaboration necessary to perform a RCA has the potential to solidify working relationships, build strong teams and transform culture within an organization.


Is Root Cause Analysis utilized by health care professionals? Absolutely. Root Cause Analysis is recommended by The Joint Commission to be used by hospitals as a methodology to study and report sentinel events. RCA is used routinely by medical device companies and the pharmaceutical industry as a quality assurance tool to uncover reasons behind adverse events. In academia, students at The University of Minnesota, School of Public Health host nationwide competitions where teams are given a case study and charged with creating a root cause analysis.


Where can I learn more about Root Cause Analysis?

The Joint Commission – www.jointcommission.org
The National Center for Patient Safety – http://www.patientsafety.gov
RCA Solutions – www.rca-fmea.com
CCD Health Systems – www.ccdsystems.com
Denise Osborn is a member of the Health Administration Section. She is a licensed attorney who works in the area of patient safety and health policy. She has a certificate in Healthcare Corporate Compliance and is a candidate for her Masters Degree in Public Health from George Washington University. Denise is the owner of RCA Solutions a consulting firm in Great Falls, Va., that provides consulting services to health care professionals. She is a senior consultant and has taught RCA to health care professionals for over 10 years. You can contact Denise directly at denise@rca-fmea.com or visit her Web site at www.rca-fmea.com


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