Root Cause Analysis
March 10, 2021
How to conduct a root cause analysis.
In response to a sentinel event occurrence, the administrative team will conduct a root cause analysis. Objectives of the root cause analysis are:
- Identify causative issues.
- System or process needing adjustment.
- Develop and implement Action Plans that will reduce the risk of recurrence.
- Monitor the effectiveness of the action plan.
- Determine the risk of recurrence.
A root cause analysis contains the following characteristics:
- Primary focus is on systems and processes, not individual performance.
- Progresses from individual cause to common causes within systems or processes.
- Focuses on core rationale for causation factors.
- Identifies necessary changes, re-design and revisions within system processes to improve the performance of employees and reduce risk of recurrence.
A team, appointed by the administrator, conducts the analysis. The team reports the findings of the analysis to the Quality Improvement Committee. The team will assign specific duties to each member for the investigation. The team will design a plan that will at least:
- Define the issues pertaining to the event.
- Determine causal factors.
- Identify contributing factors.
- Analyze factors and prioritize according to the most contributory.
- Identify systems and ineffective parts of the system that lead to the event.
- Identify actions that will benefit the facility or the organization.
- Establish a time line to assess progress of the analysis.
- Design a system for implementation of the system improvement.
- Submit a plan of improvement to the administrator and Improvement Committee.
- Determine the effectiveness of the implementation of the plan of improvement.
- Measure the impact of the change on the organization, employees and residents.
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