QI Learning Center: Utilizing Root Cause Analysis as a Problem Solving Tool

Sara MassieBy: Sara Massie, MPH, Senior Program Director, CPHQ

Have you ever encountered a complex problem and did not know where to start? Have you tried addressing a seemingly simple problem, but the issue persists?

Then it may be time to use root cause analysis (RCA), a structured way to begin solving a problem.

RCA helps you determine what happened, how it happened, and why it happened using a specific set of steps and tools. Once you’ve found the primary cause, you can then figure out what measures to take to reduce the likelihood that it will recur.

The general steps of an RCA are:

  1. Define the problem. What is the specific issue?
  2. Collect and analyze data. What is the impact of the problem, and how long has it existed?
  3. Identify causal factors. What actions/events (or lack of actions/events) contributed to the problem or made it worse?
  4. Identify the root cause(s). What is the most basic cause (why the causal factors exist)?
  5. Identify changes/solutions. What actions will help prevent the cause of the problem?
  6. Test and implement changes/solutions. Who will be part of acting on the solution? How will it be done and when?
  7. Observe the changes/solutions. Have you effectively solved the problem?

Many resources and tools are available online for conducting an RCA, so a quick web search may be helpful as you get started. In addition, the table below provides some general tips and example tools for each step. You may find that it is important to employ more than one of these techniques to be sure that you are capturing all sides of the issue.



Potential Tools*

  1. Define the problem
  • Be clear and specific about what the issue is
  1. Collect and analyze data
  • Try brainstorming with all of those who understand or are affected by the situation
  •  Quantitative data: statistical data, surveys, Pareto chart
  • Qualitative data: focus groups, interviews
  • Identify causal factors
  • Try to look at all sides of the issue and involve as many people with different perspectives as you can.
  • Try to go deep into the different reasons for the problem, thinking of as many factors as you can
  • Cause and Effect Diagram (aka Ishikawa or Fishbone Diagram)
  • 5 Whys
  • Pareto chart
  • Identify the root cause
  • Be careful not to dig so deep for the root cause that you are unable to take any action or any action that would substantially affect the problem at hand
  •  See above
  • Identify solutions
  • Be sure the solutions are practical and actionable
  • Think about what effects the solutions may have on other areas
  • SWOT analysis
  • Force field analysis
  • Stakeholder analysis
  • Evidence base (literature)
  • Test and implement solutions
  • As you plan to implement solutions, think ahead about what downstream effects the solution may have. You don’t want to end up creating other problems in other areas.
  • Action Plan
  • Flow Diagram
  • PDSA cycles
  • Observe changes
  • Make sure you observe long enough that you feel confident the problem has been resolved. It may be that your solution solved the problem in the short-term, but in the long-term, it may not be gone or other problems may have arisen.
  • PDSA cycles
  • Sustainability Checklist

*For more information on many of these tools, click here for the QI Step by Step Guide

When you are faced with a problem — be it a population health issue, a workplace process issue, or even a personal challenge  — RCA will help you find the source of the problem so you can determine the best steps for tackling it. 


Programs supported by:

BlueCross BlueShield of NC FoundatoinThe Duke Endowment

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