The Root Cause Analysis (RCA) can be approached from any level within a system to investigate and understand an identified problem. The name can be misleading but the process is employed to identify as many of the direct and contributing factors of a performance problem. The findings from an RCA can inform decisions you will make on performance improvement initiatives.

The Goals of RCA

The RCA can be broken down into three questions:

• What happened?
• Why did it happen?
• How can we prevent/reduce it from reoccurring?

The RCA Process

The process of conducting an RCA requires an investment of time from a team. Many RCA’s could take weeks to months to draft a thorough report of findings.

1. Identify the problem to investigate. It is important to have a clear definition of the problem before moving forward. Problems can include situations such as workplace incidents, employee turnover, a decline in productivity, or a decline in profits.
2. Form a team. Your team will consist of individuals with diverse roles that are internal and external to the problem area. At least one of your team members need to be knowledgeable about the processes related to the problem.
3. Document how the problem occurred. Describe the problem or incident by organizing as many details as possible.
4. List contributing factors. The contributing factors are any circumstances and/or conditions that increased the likelihood of the problem occurring.
5. List and expand upon root factors. The root factors are directly related to the problem occurring within the system.
6. Develop and design intervention(s) for the problem. Your team will continue to meet to develop solutions that can address the root causes of the problem. 
7. Assess the changes. After monitoring the deployed solutions, an evaluation should be conducted to determine if the interventions are a success.

The Tools to Identify Root Causes

The Five Why’s

 

Fishbone diagram (Ishikawa diagram)

TPN Approach to Prioritizing Root Causes

Totally within your control

Partially within your control

Not within your control

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