Adopting root-cause analyses to identify improvement opportunities

A root-cause analysis is a systematic method of identifying factors that contribute to or cause variations in performance with respect to adverse events or close calls. It allows a retrospective analysis and answers the questions: What happened? Why did it happen? How can the system or process be redesigned so that the event does not recur?

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The process is most likely accomplished by the efforts of a multidisciplinary team, but team composition can vary from one setting to another within an organization. Front-line staff are often members of the team, and patients and family members may be included in some organizations as well.

The root-cause analysis must identify the variations within the existing system or process, explore interventions that will decrease the likelihood of recurrence, and feature a robust action plan that is monitored and periodically reviewed for effectiveness. If the plan is not producing the desired outcomes, the actions must be adjusted and reviewed again until desired outcome results are achieved and maintained. 

Each organization is responsible for determining the structure of a root-cause analysis process that fits their needs, resources and care delivery model. The reporting structure of the organization should communicate what analyses have been completed, including the results of the root-cause analysis and actions that need to be taken.