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C489 Task 2 Organizational Systems and Quality Leadership

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C489 Task 2 Organizational Systems and Quality Leadership RCA and FMEA task submission. Passed with no revisions. Excellence award achieved.

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  • February 26, 2022
  • 14
  • 2021/2022
  • Essay
  • Unknown
  • A+

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C489 Organizational Systems and Quality Leadership

SAT Task 2

Barbara Maenner

Western Governors University

Instructor Leslie Ferrygood

, 2



Organizational Systems and Quality Leadership SAT Task 2



A. Root Cause Analysis

Root cause analysis (RCA) is a process that identifies causes, contributing factors, or

system failures that lead to undesirable events within a healthcare setting. RCAs are performed

after an undesirable event has occurred by a team of multiple interdisciplinary professionals to

identify causes and implement protective safeguards or improve systems that are in place to

prevent the reoccurrence of such events (Institute for Healthcare Improvement, n.d.).



A1. RCA Steps

As defined by the IHI, there are six common steps to perform a root cause analysis. Step

one is to identify what happened and when. It is important to create a timeline, possibly visually

using a diagram or flowchart, to illustrate the events that took place and when.

Step two is to determine what should have happened. This means utilizing hospital

protocols and national standards of care to identify what the correct outcome should have been.

The timeline of events for the actual outcome can then be compared to the ideal situation’s

timeline of events.

Step three is to “ask why five times”. This means analyzing causes and contributing

factors to identify why events took place when and where they did. Analyzing these factors in

this way allows the RCA team to gain insight as to why direct and indirect causes were occurring

versus just acknowledging their participation in the event. A fishbone or cause and effect

diagram may be useful to help illustrate causative factors and the role they played in the event.

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