How to Perform a Root Cause Analysis

Root cause analysis (RCA) is a process to help people understand the real causes behind a problem in order to learn why that problem arose in the first place. By digging deeper using different analysis techniques to collect data, you can then form an action plan that will enable you to identify the contributing factors of your problem in order to prevent it from occurring again.

The simplest way to think about root cause analysis is to imagine a common problem you may experience in life, like if your home Internet suddenly stopped functioning. If this occurred, you could drive to a coffee shop and use their Internet instead, but that solution would not only fail to take any corrective action but would also ignore the underlying causes of your problem. A better solution would be to call your Internet provider and ask them to find the real cause of the problem.

The primary purpose of the root cause analysis process is to analyze a problem or sequence of events in order to identify what happened, why it happened, and what can be done to prevent it from happening again.

There are three basic types of root causes that can have a potential impact on a problem:

1. 1. Physical causes: A tangible item fails for whatever reason, e.g. if an MRI machine at a hospital stops working and prevents a patient from receiving the proper health care.
2. 2. Human causes: One person or several team members did something incorrectly. Human error will often lead to a physical cause, e.g. if a hospital’s quality management team didn’t perform an MRI machine’s scheduled inspection, which caused it to fail.
3. 3. Organizational causes: When a system or process that an organization uses to do their jobs is faulty, e.g. if a hospital’s quality control department mistakenly thought it was the patient safety department’s responsibility to inspect the MRI machine and nobody corrected them.

In order to go through the RCA process, you must be familiar with the following five steps:

1. 1. Define the problem. Analyze what you see happening, and identify the precise symptoms so that you can form a problem statement.
2. 2. Gather data. Before you can move on to identifying the underlying problems, you must collect and evaluate all aspects of the situation. Performing a case study, incident investigation, or accident analysis are a few common ways to accomplish this step.
3. 3. Identify causal factors. Now with your data in hand, it’s time to look for as many causal factors as possible that could have led to your problem.
4. 4. Determine the root cause(s). Use some of the root cause analysis tools in the next section to discover the root causes of each causal factor.
5. 5. Recommend and implement solutions. Once you know the root cause, you can recommend a preventative action to ensure the problem never happens again and then develop a timeline and plan for implementing your solution. The tools in the next section can also be used to help you spot potential flaws in your solution before they happen.

The goal of RCA is to recognize all the underlying causes of a problem. Using an analysis method is a useful tool to accomplish this task. Five popular root cause analysis methods are:

1. 1. The five whys: The five whys are a problem-solving strategy that consists of asking “Why did this problem happen?” and then following the answer up with a series of additional “But why?” questions until you get to the root cause of the problem.
2. 2. Change analysis: This method meticulously examines all the changes leading up to an event in hopes of discovering risk management strategies. This is particularly useful when there are a large number of possible causes.
3. 3. Failure mode and effects analysis: One of the first systematic methods of failure analysis, FMEA a step-by-step guide for recognizing all potential failures in a product, business process, or service. Once you’ve pinpointed each individual failure in a system, you then can asses the effects of those failures one by one.
4. 4. Fishbone diagram: Also called an “Ishikawa Diagram” or a “Cause and Effect Diagram,” this RCA tool is a visual way to map cause and effect. The spine of the fish skeleton in the middle of the diagram represents the specific problem, and then the rib bones of the skeleton that branch out from the spine represent potential causes.
5. 5. Pareto analysis: This type of analysis is a statistical way of solving problems. It involves identifying a few fundamental causes of problems that must be addressed in order to solve the majority of complications. Pareto analysis assumes the 80/20 rule, which says that about 80 percent of problems are produced by only a few serious causes (20 percent).

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