Root Cause Analysis - General Process For Performing and Documenting An RCA-based Corrective Action

General Process For Performing and Documenting An RCA-based Corrective Action

Notice that RCA (in steps 3, 4 and 5) forms the most critical part of successful corrective action, because it directs the corrective action at the true root cause of the problem. The root cause is secondary to the goal of prevention, but without knowing the root cause, it is not possible to determine what an effective corrective action for the defined problem will be.

1. Define the problem or describe the event factually. Include the qualitative and quantitative attributes (properties) of the harmful outcomes. This usually includes specifying the natures, the magnitudes, the locations, and the timing of events.
2. Gather data and evidence, classifying it along a timeline of events to the final failure or crisis. For every behavior, condition, action, and inaction specify in the "timeline" what should have been done when it differs from what was done.
3. Ask "why" and identify the causes associated with each step in the sequence towards the defined problem or event. "Why" is taken to mean "What were the factors that directly resulted in the effect?"
4. Classify causes into causal factors that relate to an event in the sequence and root causes, that if eliminated, can be agreed to have interrupted that step of the sequence chain.
5. Identify all other harmful factors that have equal or better claim to be called "root causes." If there are multiple root causes, which is often the case, reveal those clearly for later optimum selection.
6. Identify corrective action(s) that will with certainty prevent recurrence of each harmful effect, including outcomes and factors. Check that each corrective action would, if pre-implemented before the event, have reduced or prevented specific harmful effects.
7. Identify solutions that, when effective, and with consensus agreement of the group, prevent recurrence with reasonable certainty, are within the institution's control, meet its goals and objectives and do not cause or introduce other new, unforeseen problems.
8. Implement the recommended root cause correction(s).
9. Ensure effectiveness by observing the implemented recommendation solutions.
10. Identify other methodologies for problem solving and problem avoidance that may be useful.
11. Identify and address the other instances of each harmful outcome and harmful factor.