CAUSAL ANALYSIS: RECOGNITION OF ROOT CAUSE

ROOT CAUSE ANALYSIS

• is a method that is used to address a problem or non-conformance, in order to get to

the “root cause” of the problem. it is used to correct or eliminate the cause, and prevent
the problem from recurring

• is a process done in response to occurrence of sentinel event

• The aim of root cause analysis is to conduct intensive analysis to reach the embedded
problems in the system and solve it

• RCA is simply the application of a series of well known, common sense techniques
which can produce a systematic, quantified and documented approach to the
identification, understanding and resolution of underlying causes

WHAT IS ROOT CAUSE?

Root cause is the fundamental breakdown or failure of a process which, when resolved,
prevents a recurrence of the problem.

RCA – SEQUENTIAL STEPS

1. Define the problem

2. Perform task/process analysis
3. Perform change/different analysis
4. Perform control barriers/safe guard analysis
5. Begin cause and effect analysis

QUALITY TOOLS
FLOWCHART
- flowchart is a pictorial representation displaying the: actual sequence of steps
and their inter- relationships in a specific process in order to identify hand-off
 (appropriate and inappropriate), inefficiencies, redundancies, inspections, and
waiting steps; and/or ideal sequence of steps, once the actual process is
known
Use when: identifying and describing a current process questioning whether
there is a process questioning whether actual process meets current
policy/procedure analyzing problems to determine causes redesigning the process
as part of the action designing a new process.

C AUSE AND
EFFECT
DIAGRAM
a) also called ishikawa or fishbone
b) the cause-and-effect diagram is a tool generally used to gather all possible
causes as an overview
c) the ultimate goal being to uncover the root cause(s) of a problem. d) the
specific problem is usually stated as a negative outcome ("effect") of a process,
e.g., late transfer of patients from the inpatient facility to skilled nursing facilities.
  ONCE THE DIAGRAM SEEMS APPROPRIATE TO THE TEAM, FURTHER
EVALUATE FOR:
o obvious improvement options
o causes already resolved or eliminated; causes easily resolved or
eliminated
o issues raised which require more in-depth assessment to be understood.

T
H
E

FIVE WHYS
A tool to help uncover the root cause or real reason for the issue it is a variation of
the approach used in fishbone analysis
when would you use it?
when you have identified an issue and want to deepen your understanding ofit and its
underlying causes it avoids group moving into ‘fix it’ mode and addressing the
symptoms of an issue without understanding the root causes quality tools
• Process of five whys
 • clearly define the issue to be tackled and write it on the left side of the paper
• complete the diagram by moving from left to right. move from the problem/issue
statement by asking the question “why?”
• ask the group “why?” and capture the responses
• for each response, again ask the question “why?”. continue to record responses
and move across to the right of the diagram. try to go to five levels of “why?”
• at the end of the analysis it is often helpful to circle the most significant insights
that have been gained.

KEPNET-TROGOE (IS-IS NOT) MATRIX

Purpose : isolate and identify causes of quality problems by assisting managers in
recognizing factors that underlie defects in a process.
Advantages:

 relates possible causes to specific categories

 identifies process problems
 simplifies development of ways to resolve the problems

BRAINSTORMING
brainstorming is a structured group process used to create as many ideas
as possible in as short a time as possible, e.g., one session, and to elicit both
individual and group creativity.

 Structured brainstorming: everyone in the group gives an idea in

rotation or passes until the next round

 Unstructured brainstorming: everyone in the group gives ideas as they

come to mind.

BENCH MARKING
all process improvement efforts require a sound methodology and implementation, and
benchmarking is no different. you need to:
• identify benchmarking partners
• select a benchmarking approach
• gather information (research, surveys, benchmarking visits)
 • distill the learning
• select ideas to implement
• pilot
• implement

COMMON ERRORS OF ROOT CAUSE

• looking for a single cause – often 2 or 3 which contribute and may be interacting
ending analysis at a symptomatic cause assigning as the cause of the problem the
“why” event that preceded the real cause

Successful application of the analysis and determination of the root cause

should result in elimination of the problem.