Root Cause Analysis and Process Improvement Plan in Healthcare

ORGANIZATIONAL SYSTEMS AND QUALITY LEADERSHIP
Name
Institutional Affiliation

Purpose of conducting root cause analysis (RCA)
Root cause analysis is a problem-solving method that is used for identifying the root
cause of a problem. A factor is considered a root cause if removal of the factor will
prevent undesirable outcome from recurring. Root cause analysis is conducted with
the objective of identifying the leading cause of a problem rather than merely
addressing the symptoms of the problem (Leonard, Joint Commission Resources &
Institute for Healthcare Improvement, 2013). After identifying the root cause, it is
possible to find a solution to the problem and hence ensure the problem does not
occur again.
Six steps of the RCA process
The following are the six steps followed when performing RCA as defined by IHI;
The first step of conducting RCA is fact gathering using a timeline and interviews.
This step requires the facilitator/investigator to review documents that are related to
the event. Such records may include medical reports and incident reports. For our case
study with nurse J who was taking care of patient B, an interview will be arranged
with both the nurse and the family of the diseased to help investigate the events that
led to the undesired situation (Myers, 2012). Medical records from the hospital and

the facility in which the patient was transferred will also be investigated to provide
information on what could have happened. The standard policy of the hospital was
that a patient who is sedated should remain on continuous B/P, ECG and pulse
oximeter until the patient meets the specific discharge criteria. The team needs to
investigate why standard procedure and policy was not followed on this patient.
The second step understands what happens. In this step, the facilitator or the person
investigating the incident should review established timelines with everyone in the
team (Hay, Levin, Deterding & Abzug, 2014). The team should then compare the
schedule of events with the actual sequence of events that should be followed
according to the policy or best practice guidelines. Patient B was left on automatic
blood pressure machine with his son. Standard procedure and systems of the hospital
require that such a patient should never be left alone and they should always be under
the care of a registered nurse. Nurse J was also allocated so many patients on that
night despite there being backup staff in the hospital. The nurse was well trained in
sedation training module and was well qualified. The nurse also did not have a history
of negligent patient care.
The third step is the determination of the root causes. The team, based on the analysis
carried out in the previous step brainstorms the root cause of the problem by asking
questions such as Why? How? The causal factors are categorised, and then the
contributing factors which would not prevent recurrence but are significant are
isolated and listed. One of the possible causes of the unfortunate event is that nurse J
failed to follow the policies and procedures laid down by the hospital management.
Step four is developing casual statements. A casual statement links the identified
causes to the effect of the problem and then to the event that prompted RCA. The
casual statements explain how contributory factors contribute to undesirable outcomes