The CAHF Quality Improvement (QI) Subcommittee has assembled this basic introduction to Root Cause Analysis (RCA) to help CAHF members understand this useful technique and use it regularly in their quality improvement activities. RCA is a team sport. At its most basic level, RCA is systematic brainstorming about the critical factors that are driving negative outcomes. To be effective, this brainstorming should always include the staff who are intimately involved in the process under review. We encourage you to use these materials to teach your staff to actively participate in the RCA process and to use a team approach that includes representatives from various disciplines in your centers. No one person has all the answers, but together, an effective team can solve almost anything.

Click here to download the 2014 QI Subcommittee RCA Toolkit (PDF)

• Introduction to Root Cause Analysis: Understanding the Causes of Events - A PowerPoint Presentation developed by the Health Services Advisory Group of California, Inc. (Click here for PDF version) (Click here for PowerPoint Version)

• Brainstorming, Affinity Grouping, and Multi-Voting Tool - QAPI (PDF)

• How to Use the Fishbone Tool for Root Cause Analysis - QAPI (PDF)

• Flowchart Guide - QAPI (PDF)

• Five Whys Tools for Root Cause Analysis - QAPI (PDF)

• A Case for Missing Laundry (PDF)

• Strategies for Reducing Falls in Long-Term Care (PDF)
  

• Performance Improvement Project and Falls Fishbone Application (PDF)