Appointing a Standing Root Cause Analysis Officer
Appointing a standing Root Cause Analysis Officer ensures that when any problem arises the RCA process will be implemented quickly. A job description should be written for the position and whether the position is a discrete one or is filled by a staff member who also fills another role in the organization depends upon the availability and resources of the organization. Sometimes it is valuable to have a rotating officer depending on the type of problem. The organization should implement the plan that best suits it as long as the position and its duties are understood by all.
1. When an incident or event occurs the RCA officer convenes the Root Cause Analysis response team, the makeup of which would be flexible depending on the incident.
2. The RCA officer leads the process of gathering the facts apropos of the incident. This
part of the RCA process is the key to the success or failure of the process. There are many ways
that this phase of the RCA can be transported out. A “brain storming” procedure could take place
where anyone close to the situation could offer opinions.
3. The 'live whys' method could be employed. This is a procedure where the question “why:
is continuously asked until the root cause is identified.
• Example: John is late for work.
• Why? His car did not start.
• Why? The battery was “dead”.
• Why? He parked it and left the lights on.
• Why? He was in a hurry.
• Why? He wanted to see a ballgame on TV.
Now this is a rather frivolous example but it shows that we have arrived at the root cause of the fact that John was late for work. Actually, this example could probably be carried out even further with more “whys”.
4. Quality tools can be brought into play, for example a “Cause and Effect Diagram” could be employed and the discussion could aim at filling in as many causes as possible. Again, remember that the people closest to the event or problem are the people who should be on the RCA team.
5. Arguably, the most important aspect of the RCA process is the desire of the RCA team
to identify the root cause. Too many times the process is short circuited because individuals close
to the problem feel that they know why the problem occurred.
6. Based on the identification of the root cause, implement an “Action Plan” that will prevent recurrence of the incident. Identify the root cause, assign responsibility for fixing the problem, assign the necessary resources, and estimate a completion time.
7. Track the “Action Plan” to determine its effectiveness.
8. Report on the Root Cause Analysis and its consequences to the CEO and Chief Medical
There are times when even a well implemented Root Cause Analysis does not arrive at the root cause. For example there may be a fraction of unknown cause and the RCA does not identify its etiology. Some staff members use this as a reason to ignore the RCA process.
It is my opinion that even in a difficult situation, such as described here the RCA will gather pertinent facts and may, by the awareness it creates, reduce further similar events