Running Head: ORGANIZATIONAL SYSTEMS TASK 2 1
Organizational Systems and Quality
Leadership SAT Task 2
Name
Western Governors University
,ORGANIZATIONAL SYSTEMS TASK 2
2
A. Root Cause Analysis
The purpose of a root cause analysis (RCA) is for an organization to better gain an
understanding of why an adverse occurred by examining system-wide problems or breakdown in
an organization’s process rather than a way to assign blame to a single person or group of
people. An RCA is done retrospectively as it is triggered by the event occurring. By following
the necessary steps to examine the true reason why an event occurred, as well as putting
interventions in place to correct the process breakdown, an RCA can prevent the error from
happening again (Institute for Healthcare Improvement, n.d.).
A1. RCA Steps
There are six steps necessary for the RCA to be an effective tool that results in process or
organizational changes to prevent a reoccurrence of the event that triggered the RCA in the first
place. These steps are:
1. Members of the RCA team must first determine exactly what events occurred and in what
sequence the events occurred that led to the adverse outcome. Some of the ways this
information is gathered are through the interview of staff members and patients or family
members, the review of patient charts, and/or the examination of organizational policies and
procedures.
2. The second step is for the RCA team to assess what should have happened if the course
of events followed the ideal sequence and there was no breakdown in the process or
organizational system.
3. The third step of the RCA process is for the team to determine what the actual root cause of
the event was. It is often helpful for the team to ask “why” five times to fine-tune the focus to
, ORGANIZATIONAL SYSTEMS TASK 3
2
the underlying cause. Some reasons for the event occurring may be direct or obvious factors
and other factors may be indirect or cause that contributed to the occurrence of the event.
4. Step four of the RCA process is completed through the creation of statements that links the
cause to the effect which then refers back to the incident that necessitated the RCA
investigation. This is referred to as a causal statement and it should have three parts to it: the
cause of an event, the results, or effect of what happened with a reference back to the
original incident.
5. The fifth step is requiring the RCA team to brainstorm some changes that they can
recommend to be implemented to prevent the incident from recurring going forward. There
are eight categories that most interventions fall under. These are the use of the same
equipment by all team members across all units, systems that require a second check or fail-
safe, a function that would physically prevent somebody from making a common mistake or
oversight, changing the physical makeup of the location where the event occurred, making
changes and or improvements to software such as an electronic health record (HER), using
visual reminders such as a label or visual cues, making the process or system easier to
navigate, educating of staff, and updating or creating new policies and procedures to reflect
the expected changes. Part of this step requires the team to identify whether the actions that
are recommended are strong and will likely prevent the issue from occurring again;
intermediate which targets the root cause of the problem; or weak. A weak action is unlikely
to be effective at preventing the incident from reoccurring but may be necessary as an initial
measure to raise awareness while strong or intermediate interventions are being put into
place.
Organizational Systems and Quality
Leadership SAT Task 2
Name
Western Governors University
,ORGANIZATIONAL SYSTEMS TASK 2
2
A. Root Cause Analysis
The purpose of a root cause analysis (RCA) is for an organization to better gain an
understanding of why an adverse occurred by examining system-wide problems or breakdown in
an organization’s process rather than a way to assign blame to a single person or group of
people. An RCA is done retrospectively as it is triggered by the event occurring. By following
the necessary steps to examine the true reason why an event occurred, as well as putting
interventions in place to correct the process breakdown, an RCA can prevent the error from
happening again (Institute for Healthcare Improvement, n.d.).
A1. RCA Steps
There are six steps necessary for the RCA to be an effective tool that results in process or
organizational changes to prevent a reoccurrence of the event that triggered the RCA in the first
place. These steps are:
1. Members of the RCA team must first determine exactly what events occurred and in what
sequence the events occurred that led to the adverse outcome. Some of the ways this
information is gathered are through the interview of staff members and patients or family
members, the review of patient charts, and/or the examination of organizational policies and
procedures.
2. The second step is for the RCA team to assess what should have happened if the course
of events followed the ideal sequence and there was no breakdown in the process or
organizational system.
3. The third step of the RCA process is for the team to determine what the actual root cause of
the event was. It is often helpful for the team to ask “why” five times to fine-tune the focus to
, ORGANIZATIONAL SYSTEMS TASK 3
2
the underlying cause. Some reasons for the event occurring may be direct or obvious factors
and other factors may be indirect or cause that contributed to the occurrence of the event.
4. Step four of the RCA process is completed through the creation of statements that links the
cause to the effect which then refers back to the incident that necessitated the RCA
investigation. This is referred to as a causal statement and it should have three parts to it: the
cause of an event, the results, or effect of what happened with a reference back to the
original incident.
5. The fifth step is requiring the RCA team to brainstorm some changes that they can
recommend to be implemented to prevent the incident from recurring going forward. There
are eight categories that most interventions fall under. These are the use of the same
equipment by all team members across all units, systems that require a second check or fail-
safe, a function that would physically prevent somebody from making a common mistake or
oversight, changing the physical makeup of the location where the event occurred, making
changes and or improvements to software such as an electronic health record (HER), using
visual reminders such as a label or visual cues, making the process or system easier to
navigate, educating of staff, and updating or creating new policies and procedures to reflect
the expected changes. Part of this step requires the team to identify whether the actions that
are recommended are strong and will likely prevent the issue from occurring again;
intermediate which targets the root cause of the problem; or weak. A weak action is unlikely
to be effective at preventing the incident from reoccurring but may be necessary as an initial
measure to raise awareness while strong or intermediate interventions are being put into
place.
