Root Cause Analysis (RCA) is a tool designed to help incident investigators describe what happened during a particular incident, to determine how it happened and to understand why it happened.
There is no single definition of a root cause but generally it can be taken as the most basic cause that can be reasonably identified and that management has the ability to control or fix – usually by taking measures that improve systems and processes.
Originally developed as a problem-solving tool in engineering, RCA has long been recognised as an essential investigation tool in fields such as engineering, quality control, safety management and environmental management.
The generic RCA process of incident investigation has been tailored to meet the specific needs of the diverse settings in which it is used.
What is a Root Cause Analysis in healthcare
In health and social care settings, RCA is used to respond to serious incidents in the workplace, particularly when determining how and why a client safety incident has occurred. Systems and processes can then be amended to prevent the same error from happening again.
Here are some real-life incidents that can lead to Root Cause Analysis in healthcare:
- The unexpected death of a patient
- A doctor misdiagnoses a patient, leading to avoidable harm
- A hospital discharges an infant to the wrong family
- A visitor steals from a care home resident
- A service user commits suicide soon after being discharged
- After surgery, an X-ray discovers a foreign body (such as gauze or a scalpel) inside a patient
- A care home experiences a virus outbreak
- A patient develops serious pressure ulcers
- Falls that result in injury
If we take the example of the unexpected death of a patient, it may be that the cause was that the patient received an incorrect dosage. The RCA would dig deeper and seek to determine how the incorrect dosage came to be administered. A timeline of the event would be created with input from all involved in the invents that led up to the incident. Analysis would then seek to determine the probable root cause, from any number of possible causes and their contributing factors.
The goal of RCA
The goal of an RCA investigation is to enable senior management to make informed decisions by determining:
- What happened
- How it happened
- Why it was able to happen
- Possible measures to take to avoid recurrence (recommendations)
It does not seek to determine the following:
- Who is to blame for an incident
- What disciplinary action should be taken
An RCA does not focus on finding and punishing individuals in the wrong. The investigation process aims to make improvements to overall systems. Or, in extreme cases, it might recommend that an organisation puts completely new systems in place. The aim is to help an organisation learn from, and avoid, similar incidents in the future. The methodology involved includes twelve steps, which come under three phases.
Root Cause Analysis is about solutions, not punishment, so the report given at the end of the RCA shouldn’t apportion blame. However, the fact that an RCA took place does not mean that nobody will be held accountable for the incident.
Root Cause Analysis Example
For example, during the COVID-19 pandemic, root cause analysis was used to review the circumstances related to COVID outbreaks within care homes in Scotland. The RCA report led to a better understanding of how to prevent and control infection in care homes across the country. The root cause analysis did not recommend any discipline against care home staff, and interviewees had the right to anonymity. This means that a staff member could admit to malpractice without being mentioned by name in the report.
If a care home involved in the RCA investigation simultaneously discovered that a staff member had caused harm by negligence or malpractice, HR would deal with this. It’s possible that a staff member would be liable for a disciplinary procedure. Still, it would not be the RCA report that recommends if and how the organisation should punish a staff member.
The three phases of an RCA investigation
An RCA investigation has three main phases: information gathering, analysis and reporting.
Most time and effort in a root cause analysis goes into the information-gathering stage. Information-gathering could include reading reports, conducting interviews, and reviewing video footage.
The more information gathered, the more likely an RCA investigation will be successful. Therefore, the investigation team should be thorough and go beyond the most obvious sources.
Root Cause Analysis Steps
The InPractice RCA methodology covered in the i2Comply training has been used successfully in the investigation of Serious Untoward Incidents (SUIs) in hospitals, care homes and care services for many years. The 12-step process enables investigators to get to the root of what happened without making assumptions. It also enables them to present findings to senior management in a way that informed decisions can be made. These decisions will facilitate the implementation of measures to prevent recurrence of the incident.
Here are the 12 steps:
- Write a timetable for the investigation
- Neutralise the incident by eliminating subjectivity
- Scoping – gather and organise information
- Produce a Simple Timeline
- Produce a detailed Tabular Timeline
- Conduct witness interviews
- Identify good practice
- Identify Care Delivery Problems
- Prioritise Care Delivery Problems
- Wagon-wheel analysis of Care Delivery Problems
- Produce the incident investigation report, including examples of good practice and identification of problem areas
- Debrief staff and follow up on the implementation of recommendations
How long does a Root Cause Analysis take?
There is no set time limit for an RCA investigation. The time taken will depend upon the complexity and seriousness of the incident. It is not unusual for an RCA investigation to take two to three months before the final report is available. In some cases, the information could take longer to put together.
The important thing to bear in mind is that a timetable is only produced once the scope of the investigation is known – and that this timetable should be strictly adhered to. If you do not stick to the timetable, it is highly likely the investigation will run and run, tying up valuable resources and failing to allow senior management to take timely decisions.
Who is involved in a Root Cause Analysis?
Typically, the organisation will form a small team to carry out the investigation. The investigation team must include members with a good understanding of the RCA processes so that they can carry out an unbiased investigation and present the findings appropriately.
The team will call on staff who might have specialist knowledge or be witnesses to the incident. Service users and family members may also be called on as witnesses.
Selecting a relevant but non-biased team helps to keep the process objective and solutions focused. But this doesn’t mean the organisation should exclude anyone from the overall process. Any staff members or service users with personal ties to the incident may be suitable interview candidates so the investigating team can get a complete picture of what happened.
The interview process could cause distress, so offering appropriate support to those involved is essential. For example, if a deceased service member’s family agrees to an interview, questions should be sensitive and relevant, and therapy services should be available where appropriate.
How to train for Root Cause Analysis?
The RCA team should be assembled immediately after an incident. For this reason, managers and specialists who could be called on should be trained in Root Cause Analysis before an incident occurs.
You can complete Root Cause Analysis training in person or online. InPractice run RCA training workshops – the essentials of which are contained in the i2Comply RCA online training.
The benefits of an online RCA course include the following:
- Training is self-paced so that team members can qualify around their work commitments and personal lives.
- Team members don’t have to travel long distances to training centres.
Online RCA courses are typically more affordable than face-to-face training.
Root Cause Analysis Online Training
If you would like to delve deeper, you may be interested in the RCA for Incident Investigation Training. This affordable Root Cause Analysis training is designed for a wide range of settings and is appropriate for a complete beginner. It is accredited by the CPD Certification Scheme.
If you have any further questions about the training, or for information about discounts with larger orders, please get in touch at [email protected] or give us a call on 0333 577 5016. We’ll be more than happy to help.