RCA Process

There is no single problem solving process that is capable of producing results in every situation; however, the robust RCA process illustrated below can significantly increase the chances of success and prevent recurrence of undesirable outcomes. It is not always necessary to follow the RCA process steps in a sequential order. In order to increase the speed and efficiency of the RCA process many of the process steps can be performed simultaneously. Depending on the impact, probability of recurrence, level of complexity, and other unique circumstances surrounding the event, the depth of analysis and overall scope of the RCA will be considerably different. Given the vast array of tools and techniques suitable for the RCA, it is important to keep the process simple and cost-effective by selecting and using only the most relevant tools for each phase of the process.

 

RCA Process

 

 

No. RCA Steps Description
1 Initial Response
  • Address immediate needs of the affected individuals
  • Secure evidence, record relevant facts and report the event
  • Initiate the disclosure process as appropriate
  • Implement immediate containment measures
2 Preparation
  • Organize an interprofessional RCA team with clear mandate
  • Develop Project Charter and ensure leadership support
  • Define the scope of the problem and select analytical methods
  • Identify and engage key stakeholders in the process
3 Data Collection and Analysis
  • Conduct structured interviews and observe processes
  • Determine the sequence and timeline of events
  • Develop process maps and examine the human-system interactions
  • Collect and analyze qualitative and quantitative data
  • Identify immediate causes and contributing factors
  • Review relevant literature, standards, policies, and procedures
4 Root Cause Identification
  • Identify and categorize all possible root causes
  • Examine interrelationships among causes and contributing factors
  • Select the most likely root causes
  • Identify information gaps and conduct further investigation
  • Determine and validate the true root causes
5 Solution Design
  • Define design requirements
  • Review best practices and known solutions from other sources
  • Identify and prioritize possible solutions
  • Select attainable systems-based solutions for implementation
  • Complete pilot testing, evaluate usability and determine effectiveness
  • Prepare the RCA report for review and further validation
6 Implementation
  • Develop a Project Management Plan to guide implementation
  • Identify and address quality, safety and resource requirements
  • Roll out education and communication plan
  • Continually identify new risks and implement risk response strategies
  • Define key measures, monitor and control implementation of the plan
7 Evaluation
  • Review complementary outcome, process and balancing measures
  • Evaluate effectiveness of the implemented solutions
  • Refine solutions and mitigate remaining risks
  • Accept deliverables and transfer responsibilities to the process owner
  • Communicate results and provide post-RCA disclosure as appropriate
8 Continuous Improvement
  • Institutionalize the change and spread improvements
  • Establish process for systematic monitoring of performance
  • Develop process improvement capability in the workforce
  • Share the lessons learned within and outside the organization
  • Create a culture of safety and build a system-focused organization