| A major challenge in process improvement is getting to the root of the problem or opportunity. Root cause analysis (RCA) is a term used to describe a systematic process for identifying contributing causal factors that underlie variations in performance. This structured method of analysis is designed to get to the underlying cause of a problem - which then leads to identification of effective interventions that can be implemented in order to make improvements. RCA helps teams understand that the most immediate or seemingly obvious reason for the problem or an event may not be the real reason that an event occurred. The RCA process leads to digging deeper and deeper - looking for the reasons behind the reasons. This process will generally lead to the identification of more than one root cause. The root cause(s) and any contributing factors can then be sorted into categories to facilitate the identification of various actions that can be taken to make improvements. RCA focuses primarily on systems and processes, not individual performance. The RCA process takes practice, but can be a valuable tool for performance improvement. In order to get familiar with RCA you and your team may consider:
- Studying case examples of RCAs.
- Applying RCA to an adverse event and discussing this technique with the team.
- Building RCA examples into training opportunities.
For more information on this topic, read page 18 of QAPI at a Glance.
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