1. Identify the event to be investigated and gather preliminary information
Events and issues can come from many sources (e.g., incident report, risk management referral, resident or family complaint, health department citation). The facility should have a process for selecting events that will undergo an RCA.
2. Charter and select team facilitator and team members
Leadership should provide a project charter to launch the team. The facilitator is appointed by leadership. Team members are people with personal knowledge of the processes and systems involved in the event to be investigated.
3. Describe what happened
Collect and organize the facts surrounding the event to understand what happened.
4. Identify the contributing factors
The situations, circumstances or conditions that increased the likelihood of the event are identified.
5. Identify the root causes
A thorough analysis of contributing factors leads to identification of the underlying process and system issues (root causes) of the event.
6. Design and implement changes to eliminate the root causes
The team determines how best to change processes and systems to reduce the likelihood of another similar event.
7. Measure the success of changes
Like all improvement projects, the success of improvement actions is evaluated.