Root Cause Analysis
1. A Root Cause Analysis (fishbone chart) is often the first step in problem-solving a quality management initiative.
2. Identify a problem (clinical or other) and work through the steps. Since this is usually a group effort, it will be helpful to obtain input from others who are also aware of and affected by the "problem."
3. Submit a Fishbone Chart of the found Root Cause Analysis.
a. Example of a Blank Fishbone Chart
https://www.vertex42.com/Files/pdfs/2/cause-andeffect-diagram.pdf
b. Example of a completed Fishbone
I. Communication
II. policies and procedure
III. Monitoring
IV. Education
V. Environment
VI. Documentation
4. Discuss the following information in your Fishbone Chart as well as analysis paper (refer to the #5 directions below):
a. Identify the problem i. Must be very clear about the problem ii. Include when/where it occurs b. Identify major factors involved
i. These may be people (no names), systems, equipment, materials, external factors, etc.
ii. Each is listed as a separate entry
iii. Brainstorm with others c. Identify at least three (3) to six (6) possible causes for each of the major factors identified
- Identify all potential factors for each and list them separately
ii. Some may be "sub-causes" of others
iii. Continue until no further causes can be identified d. The key is to focus on why the "problem" occurs (don't focus on the history or the symptoms of the problem).
5. Also, submit a brief Analysis Paper discussing the following:
a. Complexity of the problem
i. Why is this a problem? ii. What is the impact of the problem?
b. Process of analysis i. How do you interpret the data on the chart?
ii. What is it telling you?
c. Top two (2) probable causes d. One (1) intervention
i. Be specific about the best approach to address the identified issue.
6. List References