Running Head: Task 1
2
WGU C489 ORGANIZATIONAL SYSTEMS AND QUALITY
LEADERSHIP - TASK 2
Western Governors University
, Task 2 2
A.
The main justification for doing an investigation of the root cause is to solve a problem.
You need to be able to identify what the problem(s) are, and what the causes are to solve a
problem. The main purpose of using RCA (Root Cause Analysis) is to determine what has
occurred, how it has happened, and why. Conducting an RCA helps the investigator locate the
source from which the problem originates, thus enabling them to solve the problem, and helps
put in place measures to prevent the problem from occurring again in the future.
A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
Step one in using an RCA is to identify what happened. The data must be as accurate as
possible and as detailed as possible. You may construct a flowchart to help in visualizing the
process and clarifying the order of events. You are discovering the truth in that step of the
process. To be correct, you need to check the incident report and the medical chart of the patient.
The information collection shouldn't be done by the people involved in the incident.
Step two is deciding what ought to have happened. The team members will have to
decide in "ideal conditions" what should have happened. Also, a flowsheet in this step could be
useful in comparing it to the flowsheet one generated in the first step.
Step three is stating, "Why?" five times to determine the cause. This is where the team
looks at and decides factors that contributed to the incident. This involves both the most
apparent reasons and indirect ones. With this step, a fishbone diagram could be useful for
exploring and showing the possible causes of a particular effect.
Step four is to develop causal statements that connect the cause to the effect, and then
2
WGU C489 ORGANIZATIONAL SYSTEMS AND QUALITY
LEADERSHIP - TASK 2
Western Governors University
, Task 2 2
A.
The main justification for doing an investigation of the root cause is to solve a problem.
You need to be able to identify what the problem(s) are, and what the causes are to solve a
problem. The main purpose of using RCA (Root Cause Analysis) is to determine what has
occurred, how it has happened, and why. Conducting an RCA helps the investigator locate the
source from which the problem originates, thus enabling them to solve the problem, and helps
put in place measures to prevent the problem from occurring again in the future.
A1. Explain each of the six steps used to conduct an RCA, as defined by IHI.
Step one in using an RCA is to identify what happened. The data must be as accurate as
possible and as detailed as possible. You may construct a flowchart to help in visualizing the
process and clarifying the order of events. You are discovering the truth in that step of the
process. To be correct, you need to check the incident report and the medical chart of the patient.
The information collection shouldn't be done by the people involved in the incident.
Step two is deciding what ought to have happened. The team members will have to
decide in "ideal conditions" what should have happened. Also, a flowsheet in this step could be
useful in comparing it to the flowsheet one generated in the first step.
Step three is stating, "Why?" five times to determine the cause. This is where the team
looks at and decides factors that contributed to the incident. This involves both the most
apparent reasons and indirect ones. With this step, a fishbone diagram could be useful for
exploring and showing the possible causes of a particular effect.
Step four is to develop causal statements that connect the cause to the effect, and then
