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C489 Organizational Systems and Quality Leadership
SAT Task 2
Barbara Maenner
Western Governors University
Instructor Leslie Ferrygood
, 2
Organizational Systems and Quality Leadership SAT Task 2
A. Root Cause Analysis
Root cause analysis (RCA) is a process that identifies causes, contributing factors, or
system failures that lead to undesirable events within a healthcare setting. RCAs are performed
after an undesirable event has occurred by a team of multiple interdisciplinary professionals to
identify causes and implement protective safeguards or improve systems that are in place to
prevent the reoccurrence of such events (Institute for Healthcare Improvement, n.d.).
A1. RCA Steps
As defined by the IHI, there are six common steps to perform a root cause analysis. Step
one is to identify what happened and when. It is important to create a timeline, possibly visually
using a diagram or flowchart, to illustrate the events that took place and when.
Step two is to determine what should have happened. This means utilizing hospital
protocols and national standards of care to identify what the correct outcome should have been.
The timeline of events for the actual outcome can then be compared to the ideal situation’s
timeline of events.
Step three is to “ask why five times”. This means analyzing causes and contributing
factors to identify why events took place when and where they did. Analyzing these factors in
this way allows the RCA team to gain insight as to why direct and indirect causes were occurring
versus just acknowledging their participation in the event. A fishbone or cause and effect
diagram may be useful to help illustrate causative factors and the role they played in the event.
C489 Organizational Systems and Quality Leadership
SAT Task 2
Barbara Maenner
Western Governors University
Instructor Leslie Ferrygood
, 2
Organizational Systems and Quality Leadership SAT Task 2
A. Root Cause Analysis
Root cause analysis (RCA) is a process that identifies causes, contributing factors, or
system failures that lead to undesirable events within a healthcare setting. RCAs are performed
after an undesirable event has occurred by a team of multiple interdisciplinary professionals to
identify causes and implement protective safeguards or improve systems that are in place to
prevent the reoccurrence of such events (Institute for Healthcare Improvement, n.d.).
A1. RCA Steps
As defined by the IHI, there are six common steps to perform a root cause analysis. Step
one is to identify what happened and when. It is important to create a timeline, possibly visually
using a diagram or flowchart, to illustrate the events that took place and when.
Step two is to determine what should have happened. This means utilizing hospital
protocols and national standards of care to identify what the correct outcome should have been.
The timeline of events for the actual outcome can then be compared to the ideal situation’s
timeline of events.
Step three is to “ask why five times”. This means analyzing causes and contributing
factors to identify why events took place when and where they did. Analyzing these factors in
this way allows the RCA team to gain insight as to why direct and indirect causes were occurring
versus just acknowledging their participation in the event. A fishbone or cause and effect
diagram may be useful to help illustrate causative factors and the role they played in the event.
