00_RCA09_frontmatter.

indd 1 10/29/09 5:46:50 PM

 Senior Editor: Lori Meek Schuldt
Project Manager: Bridget Chambers
Managers, Publications: Paul Reis, Victoria Gaudette
Associate Director, Production: Johanna Harris
Associate Director, Editorial Development: Diane Bell
Executive Director: Catherine Chopp Hinckley, Ph.D.
Joint Commission/JCI Reviewers: Maureen Carr, Gerard Castro, Anita Giuntoli, Robert Katzfey,
Paul vanOstenberg, John Wallin, Sherri Woods

Joint Commission Resources Mission

The mission of Joint Commission Resources is to continuously improve the safety and quality of care in the United States and in the
international community through the provision of education, publications, consultation, and evaluation services.

Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The
Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources
publications receive no special consideration or treatment in, or confidential information about, the accreditation process.

The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed
as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be
construed as disapproval.

This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. Every attempt
has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject
to change. Please also note that some of the examples in this publication are specific to the laws and regulations of the locality of the
facility. The information and examples in this publication are provided with the understanding that the publisher is not engaged in
providing medical, legal, or other professional advice. If any such assistance is desired, the services of a competent professional person
should be sought.

© 2010 Joint Commission on Accreditation of Healthcare Organizations

Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint
Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The
Joint Commission.

All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the
publisher.

Printed in the U.S.A. 5 4 3 2 1

Requests for permission to make copies of any part of this work should be mailed to
Permissions Editor
Department of Publications
Joint Commission Resources
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181 U.S.A.
permissions@jcrinc.com

ISBN: 978-1-59940-318-2
Library of Congress Control Number: 2009931192

For more information about Joint Commission Resources, please visit http://www.jcrinc.com.

00_RCA09_frontmatter.indd 2 10/29/09 5:46:51 PM

 Contents
Foreword vii

Introduction ix

Chapter 1. Root Cause Analysis: An Overview 1

What Is Root Cause Analysis? 1
When Can a Root Cause Analysis Be Performed? 2
Variation and the Difference Between Proximate and Root Causes 6
Benefits of Root Cause Analysis 7
Maximizing the Value of Root Cause Analysis 11
The Root Cause Analysis and Action Plan: Doing It Right 11

Chapter 2. Addressing Sentinel Events in Policy and Strategy 23

Sentinel Events and the Range of Adverse Events in Health Care 23
The Joint Commission’s Sentinel Event Policy 26
Joint Commission International’s Sentinel Event Policy 33
Developing an Organization’s Sentinel Event Policy 39
Leadership, Culture, and Sentinel Events 40
Early Response Strategies 40
Event Investigation 41
Onward with Root Cause Analysis 45

Chapter 3. Preparing for Root Cause Analysis 47

Step 1: Organize a Team 47
Step 2: Define the Problem 53
Step 3: Study the Problem 58

Chapter 4. Determining What Happened and Why: The Search for Proximate Causes 71
Step 4: Determine What Happened 71
Step 5: Identify Contributing Process Factors 72
Step 6: Identify Other Contributing Factors 73
Step 7: Measure—Collect and Assess Data on Proximate and Underlying Causes 76
Step 8: Design and Implement Immediate Changes 79

iii

00_RCA09_frontmatter.indd 3 10/29/09 5:46:52 PM

 ROOT CAUSE ANALYSIS IN HEALTH CARE: TOOLS AND TECHNIQUES, FOURTH EDITION

Chapter 5. Identifying Root Causes 85

Step 9: Identify Which Systems Are Involved—The Root Causes 85
Step 10: Prune the List of Root Causes 90
Step 11: Confirm Root Causes and Consider Their Interrelationships 91

Chapter 6. Designing and Implementing an Action Plan for Improvement 95

Step 12: Explore and Identify Risk Reduction Strategies 95
Step 13: Formulate Improvement Actions 104
Step 14: Evaluate Proposed Improvement Actions 107
Step 15: Design Improvements 108
Step 16: Ensure Acceptability of the Action Plan 113
Step 17: Implement the Improvement Plan 113
Step 18: Develop Measures of Effectiveness and Ensure Their Success 118
Step 19: Evaluate Implementation of Improvement Efforts 120
Step 20: Take Additional Action 120
Step 21: Communicate the Results 121

Chapter 7. Tools and Techniques 137

What Is Lean Six Sigma? 137
Affinity Diagram 140
Brainstorming 142
Change Analysis 144
Change Management 145
Check Sheet 146
Control Chart 148
Failure Mode and Effects Analysis (FMEA) 150
Fishbone Diagram 152
Flowchart 154
Gantt Chart 156
Histogram 157
Kaizen 158
Multivoting 160
Operational Definition 161
Pareto Chart 162
Relations Diagram 164
Scatter Diagram 166
SIPOC Process Map 168
Stakeholder Analysis 170
Standard Work 172
Value Stream Mapping 174

iv

00_RCA09_frontmatter.indd 4 10/29/09 5:46:52 PM

 Contents

Chapter 8. Root Cause Analysis Case Studies from the Field 177
Root Cause Analysis of Heparin-Induced Thrombocytopenia (HIT) Leads to
Earlier Identification and Intervention 177
Root Cause Analysis of Surgical Site Infections Spurs Reforms That Improve
Patient Safety and Save Money 179
Removal of Wrong Kidney Triggers Root Cause Analysis Leading to Process Improvement 182
Root Cause Analysis Training Helps Reduce Falls in Rural Health Care Facilities 185
Learning to Improve Safety: False-Positive Pathology Report Results in Wrongful Surgery 193
Using Aggregate Root Cause Analysis to Reduce Falls and Related Injuries 202

Glossary 213

Index 223

00_RCA09_frontmatter.indd 5 10/29/09 5:46:52 PM

 ROOT CAUSE ANALYSIS IN HEALTH CARE: TOOLS AND TECHNIQUES, FOURTH EDITION

vi

00_RCA09_frontmatter.indd 6 10/29/09 5:46:52 PM

 Foreword
In my 19 years with The Joint Commission, I have been
privileged to be part of what we can now rightly call the
patient safety movement. That I was swept up by the
early excitement of acknowledging and confronting the
health care safety challenge in the mid-1990s was, for
me, not so much a surprise as a “well, it’s about time”
moment. You see, it had been 30 years since I had first
studied serious adverse events, actual and potential, and
applied root cause analysis and failure mode and effects
analysis to understand and prevent them. No, this wasn’t
about health care adverse events. After all, at that time,
if bad patient outcomes occurred at all—rare events,
indeed, in that age of denial—it was either the provider’s
fault (bad doctor, bad nurse) or the patient’s fault (bad
disease, frail condition). This was in a quite different
environment, or so it seemed at the time: I was a systems
engineer in the U.S. space program. It was the 1960s.
This was Project Apollo; the Saturn V; the Lunar Mod-
ule. If things went wrong, or might go wrong, it was not
because a person made an error but because a system
failed. As engineers, we understood that people make
mistakes and that this is not a cause of failure but rather
a condition of function that must be incorporated into
the design of systems. And so, 30 years hence, the idea
that engineering and health care might have something
in common began to emerge. This notion was exciting
to some and offensive to others. But it was increasingly
difficult to deny that bad things were happening in
health care, even in the best hospitals, with the most
experienced and dedicated doctors and nurses using
state-of-the-art equipment. Could it be that the causes
were deeper than human error?
In 1995, with multiple “medical errors” exploding across
the front pages of the nation’s newspapers, the word
vii
00_RCA09_frontmatter.indd 7
safety did not appear in the Joint Commission’s mission
statement, nor did the phrases “sentinel event” or “root
cause analysis” appear in its standards. Paul Schyve,
then and now senior vice president at the Joint Commis-
sion, and I were flying around the country to visit with,
console, and cajole hospitals that had recently experi-
enced serious adverse events and guide them through
the stages of denial, anger, bargaining, depression, and
finally acceptance: it happened; we’re not bad people; we
want to do the right thing; help us understand why this
happened; help us keep it from happening again. As it
turned out, Paul’s background as a psychiatrist and mine
as a systems engineer–turned–surgeon proved to be a
good mix of competencies for the job at hand.
Within a year, sentinel event was formally defined for
health care; the application of root cause analysis to
health care events had been outlined; a free, 20-page,
blue-covered pamphlet titled A Framework for Root
Cause Analysis in Response to a Sentinel Event became the
hottest product of the Joint Commission’s publication
department; and a draft of the Joint Commission’s first
Sentinel Event Policy was on its way to the Accredita-
tion Committee. We preached the virtues of a nonpuni-
tive response to sentinel events, yet ironically our own
response to accredited organizations that experienced
sentinel events was to put them into Conditional Ac-
creditation. It was quickly apparent that this was not
helpful, nor was the cosmetic “improvement” of Ac-
creditation Watch that replaced it (and has since been
discontinued). We are in a better place now when the oc-
currence of a sentinel event has no impact on accredita-
tion status; only the failure to respond to a sentinel event
in an appropriate manner can influence the accreditation
decision.
10/29/09 5:46:53 PM
 ROOT CAUSE ANALYSIS IN HEALTH CARE: TOOLS AND TECHNIQUES, FOURTH EDITION
Since then, reporting of sentinel events has steadily
increased, root cause analysis has been accepted as the
appropriate response, and the quality of those analyses
has improved dramatically, helped in no small measure
by Root Cause Analysis in Health Care: Tools and Tech-
niques, now in its fourth edition. This is must reading
for all quality improvement professionals, patient safety
officers, and risk managers and a valuable resource for all
who aspire to clinical or administrative leadership roles
in any health care organization.
In addition to refining the techniques of event analysis,
improvement planning, and effectiveness measurement
as they have evolved since the first edition of this work
in 2000, the Fourth Edition broadens the applicabil-
ity and usefulness of root cause analysis while directly
addressing the current key questions of the patient safety
movement: With all we have studied and all we have
learned, why are we still seeing sentinel events in alarm-
ing numbers? Is root cause analysis worth the time and
effort it takes to do it well? Are we asking the right ques-
tions? Are we doing the right things? Are we doing them
correctly? There are important research implications
viii
00_RCA09_frontmatter.indd 8
here: Do root cause analyses of near-miss events produce
the same patterns of causation as root cause analyses of
events that resulted in harm? Are the patterns of event
causation found in voluntary reporting programs (such
as the Joint Commission’s) representative of the patterns
of causation for similar events occurring in the general
population of health care organizations? Do root cause
analyses undergoing criteria-based independent review
and refinement produce patterns of causation compa-
rable to those of unsupervised root cause analyses? Will
standardization of processes improve safety in health
care as it has in other high-risk fields?
As you read this book, I believe you will be persuaded
both that we have made great progress and that there
is much left to do. Root Cause Analysis in Health Care:
Tools and Techniques, Fourth Edition is your field guide
for this next great adventure in patient safety.
—Richard J. Croteau, M.D.
Patient Safety Advisor,
Joint Commission International
10/29/09 5:46:53 PM
 Introduction
When the American actor Dennis Quaid’s hospital-
ized newborn twins received a massive dose of the
blood thinner heparin—about 1,000 times the amount
intended—they almost died.1,2 The November 2007
incident brought medical errors into the media spotlight
and heightened public consciousness worldwide.
Quaid and his family soon discovered that the error was
not an isolated incident. Unfortunately, errors are all too
common in health care, and some patients do not sur-
vive them. For example, a similar incident resulted in the
deaths of three infants in another hospital a year before
the Quaid family’s ordeal.2
In collaboration with the health care professionals in-
vestigating his situation, Quaid also discovered that the
incident that harmed his children was not caused by the
negligence of one clinician. Rather, the cause was traced
to a chain of errors starting with the pharmaceutical
manufacturer and linking on up the line through the
hospital pharmacy, the pediatric ward, and finally the
administering nurse.2
Since the incident, Quaid has embraced the issue of
patient safety by establishing a foundation and by using
his celebrity to draw continuing media attention to the
issue.2 The Quaid story has brought two important ideas
to the forefront: First, medical errors can cause serious
harm or death and are a problem that can affect anyone;
and second, to address medical errors—and actually
solve problems—health care organizations must dig deep
to unearth the root cause(s) and then develop solutions
that address the problems from a systems perspective.
Indeed, the very presence of medical errors indicates
a continuing paradox in modern medicine. Despite
ix
00_RCA09_frontmatter.indd 9
remarkable advances in almost every field of medicine,
the occurrence of errors, or failures—the term used
increasingly instead of errors—persists. When such
failures harm individuals receiving health care services,
the problem is extremely disturbing. Many if not most
failures and sentinel events—that is, unexpected occur-
rences involving death or serious physical or psychologi-
cal injury, or the risk thereof—are the result of system
and process problems. These problems inherently cause
failures to occur and individuals to be harmed.
The Quaid incident occurred about seven years after such
problems had been thrust into the limelight with the
watershed report To Err Is Human: Building a Safer Health
System, published in 2000 by the Institute of Medicine
(IOM). The IOM report, however, was just the tip of
the iceberg. Many other reports followed, illustrating
the need to improve the quality of care being delivered
in the United States. For example, researchers at Johns
Hopkins Children’s Center and the Agency for Health-
care Research and Quality reviewed 5.7 million records
of patients under 19 years of age from 27 states who were
hospitalized in 2000. Of the 52,000 children identified
by the researchers as being harmed by unsafe medical care
during their hospital stays, 4,483 suffered a fatal injury.3
These quality-of-care issues are a problem for hospitals
around the world. According to a 2007 report, hospital
chart reviews in various countries indicate that adverse
events in acute care hospital admissions range from
2.9% in the United States to 5.0% in the United King-
dom, 7.5% in Canada, 12.5% in New Zealand, and 16%
in Australia.4
Although these reports and chart reviews illuminate the
problem, it is virtually impossible to know how many
10/29/09 5:46:53 PM
 ROOT CAUSE ANALYSIS IN HEALTH CARE: TOOLS AND TECHNIQUES, FOURTH EDITION
patients suffer as a result of medical failures; however,
any single failure, error, or sentinel event is a cause for
concern. Sentinel events can result in tragedy for indi-
viduals served and their families, add costs to an already
overburdened health care system, adversely affect the
public’s perception of an organization, and lead to litiga-
tion. They can also deeply affect health care profession-
als who are dedicated to helping individuals receiving
care, treatment, or services.
Health care organizations, then, have no choice but to
answer one key question: Why do these errors or failures
continue to occur?
To get an answer, health care organization leaders need
to consider root cause analysis—a process for identify-
ing the basic or causal factor(s) underlying variation in
performance, including the occurrence or possible oc-
currence of a sentinel event—and all of its related tools
as a means toward safer health care services. That is, root
cause analysis can be used to uncover the underlying
factors that lead to errors and failures and subsequently
move organizations to deliver care without such mis-
takes, which in turn will improve the overall quality of
care that patients receive.
Although health care organizations in the United States
often use root cause analysis to help improve quality en
route to accreditation, such analysis has many broader
applications around the world. After all, high-quality
care is high-quality care, whether it is delivered in
New York City or Dubai or Singapore. Organizations
worldwide need to consider how root cause analysis can
be used to help take quality improvement in the right
direction.
The Current Health Care Environment
Health care continues to experience dramatic change.
As health care organizations become more complex,
their systems and processes are increasingly interdepen-
dent and are often interlocked and coupled. This
interconnectedness increases the opportunity for failure
and makes the recovery from failure by those involved
more difficult. The rapid explosion of the medical
knowledge base has made it increasingly challenging for
practitioners to stay up-to-date. Despite technological
00_RCA09_frontmatter.indd 10
advances and great gains in knowledge, health care
systems are, and will continue to be, appropriately
dependent on human intervention. The rigorous finan-
cial constraints imposed by managed care and the need
to reduce health care expenditures have affected every
type of health care organization. No organization is
immune. Organization leaders are reassessing their
workforces. Work loads are heavier, creating increased
stress and fatigue for health care professionals. Caregivers
are working in new settings and performing new
functions, sometimes with minimal training. Skill mixes
are shifting. As life expectancies increase and diseases
become ever more challenging, health care providers are
not only caring for older patients than in the past, but
they are faced with more severe diseases and conditions.
In short, the health care environment is ripe for serious
problems caused by systems failures.
Health care organizations are constantly evolving
because of changes in reimbursement, new technol-
ogy, regulatory requirements, and staffing levels. These
modifications cause policies and procedures to change
often and, in most cases, quickly. As a result, it is dif-
ficult to maintain consistency in processes and systems,
which leads to variation. Often, this variation results in
increased failure risk.
Instances of errors and sentinel events within health
care organizations have been reported in the media with
increasing regularity. These events cast a shadow on
the public’s trust of health care. People justifiably ask,
“What’s going on?” Failure detection, reduction, and
prevention strategies are receiving needed new impetus
as the health care industry recognizes the need for a pro-
active approach to reduce the risk of failure. Regulatory
and accrediting agencies have responded to the public’s
concerns and the data outlining the medical errors by
developing and revising standards and survey processes
to emphasize that the primary focus is patient safety.
The use of root cause analysis is also expanding. Instead
of merely being seen as a tool to investigate sentinel
events, root cause analysis is now being used to delve
into the causation associated with a series of less-
serious errors and near misses. In essence, health care
organizations no longer have to wait until a serious,
10/29/09 5:46:53 PM

life-threatening event occurs to enact a root cause
analysis program. Instead, organizations can begin to
improve quality by addressing less-tragic—but still
important—events as well as the near misses that by
good fortune have not done harm but signal the risk of
harm in the future.
When an adverse outcome, a sentinel event, or a cluster
of less-serious incidents or near misses occurs, organiza-
tions must develop an understanding of the contribut-
ing factors—the fundamental reasons a problem has
occurred—and the interrelationship of those factors.
Next, the organization must implement improvement
or redesign efforts to be more resilient. Resilience is the
degree to which a system continuously prevents, detects,
mitigates, or ameliorates hazards or incidents. It is clear
that general knowledge about adverse events is limited at
best. General knowledge is even more limited in the area
of proactive design or redesign of health care processes
and systems. These design aspects aim to prevent or at
least minimize the likelihood of future failures and to
protect individuals from the harmful effects of failures
when they do occur.
Purpose of the Book
Root Cause Analysis in Health Care: Tools and Techniques,
Fourth Edition is intended to help health care organiza-
tions prevent systems failures by using root cause analy-
sis to do the following:
• Identify causes and contributing factors of a sentinel
event or a cluster of incidents
• Implement risk reduction strategies that decrease the
likelihood of a recurrence of the event or incidents
• Determine effective and efficient ways of measuring
and improving performance
Root cause analysis is an effective technique most
commonly used after an error has occurred to identify
underlying causes. Failure mode and effects analysis
(FMEA) is a proactive technique used to prevent process
and product problems before they occur. Health care
organizations should learn both techniques to reduce
the likelihood of adverse events. This book on root cause
analysis and its companion volume on FMEA5 outline
both of these approaches of examining systems failures
in a step-by-step manner.
xi
00_RCA09_frontmatter.indd 11
Introduction
Root Cause Analysis in Health Care: Tools and Techniques,
Fourth Edition provides health care organizations with
up-to-date information on the Joint Commission’s
Sentinel Event Policy and safety-related requirements. It
also describes the similar Sentinel Event Policy of Joint
Commission International. The book includes examples
that guide the reader through application of root cause
analysis to the investigation of specific types of sentinel
events, such as medication errors, suicide, treatment
delay, and elopement. For ease of access and use by root
cause analysis teams, practical checklists and worksheets
are offered at the end of each chapter.
This publication provides and explains the Joint Com-
mission’s framework for conducting a root cause analy-
sis. It also helps organizations do the following:
• Identify the processes that could benefit from root
cause analysis
• Conduct a thorough and credible root cause analysis
• Interpret analysis results
• Develop and implement an action plan for improve-
ment
• Assess the effectiveness of risk reduction efforts
• Integrate root cause analysis with other programs
It is our hope that even without the occurrence of an
adverse event, health care organizations will embrace
the use of root cause analysis to investigate near misses
in order to minimize the possibility of future failures
and thereby to improve the care, treatment, and services
provided at their facilities.
Overview of Contents
Root Cause Analysis in Health Care: Tools and Tech-
niques, Fourth Edition provides health care organizations
with practical, how-to information on conducting a
root cause analysis. Twenty-one steps are described (in
Chapters 3 through 6). Teams conducting a root cause
analysis might not follow these steps in a sequential
order. Often, numerous steps will occur simultaneously,
or the team will return to earlier steps before proceeding
to the next step. It is critical for teams to customize or
adapt the process to meet the unique needs of the team
and organization. Appropriate tools for use in each stage
of root cause analysis are identified in each chapter. A
chapter-by-chapter description of the contents follows.
10/29/09 5:46:54 PM
 ROOT CAUSE ANALYSIS IN HEALTH CARE: TOOLS AND TECHNIQUES, FOURTH EDITION
Chapter 1, “Root Cause Analysis: An Overview,” takes
a holistic look at root cause analysis. It describes varia-
tion, how proximate and root causes differ, when root
cause analysis can be conducted, and the benefits of root
cause analysis. One of the benefits involves effectively
meeting Joint Commission and Joint Commission Inter-
national requirements that relate to the management of
sentinel events. The chapter also provides guidelines on
the characteristics of a thorough and credible root cause
analysis and action plan.
Chapter 2, “Addressing Sentinel Events in Policy and
Strategy,” describes the types of adverse events occurring
in health care. The Joint Commission’s Sentinel Event
Policy and requirements are listed in full, including a
description of reportable and reviewable events. Joint
Commission International’s Sentinel Event Policy also
is discussed. The chapter provides practical guidelines
on how an organization can develop its own sentinel
event policy, including the role that an organization’s
culture and leadership play in risk reduction and preven-
tion. It describes the need for root cause analysis and
provides practical guidance on the early steps involved
in responding to an adverse or sentinel event. These steps
include prompt and appropriate care provided to the pa-
tient, risk containment to minimize the possibility of a
similar event recurring immediately with other patients,
event investigation so that the organization can explore
exactly what occurred and learn from the event, and
appropriate communication and disclosure to relevant
parties.
Chapter 3, “Preparing for Root Cause Analysis,” cov-
ers the early steps involved in performing a root cause
analysis. The first of four hands-on workbook chapters,
it describes how to organize a root cause analysis team,
define the problem, and gather the information and
measurement data to study the problem. Details are
provided about team composition and ground rules. The
chapter also covers how to use information gleaned from
the Joint Commission’s Sentinel Event Database and
accreditation requirements to identify problem areas in
need of root cause analysis. The chapter provides guid-
ance on recording information obtained during a root
cause analysis, conducting interviews, and gathering
physical and documentary evidence.
xii
00_RCA09_frontmatter.indd 12
Chapter 4, “Determining What Happened and Why:
The Search for Proximate Causes,” provides practical
guidance on the next stage of root cause analysis—de-
termining what happened and the reasons it happened.
Organized in a workbook format, the chapter describes
how to further define the event, identify process prob-
lems, determine which care processes are involved with
the problem, and pinpoint the human, process, equip-
ment, environmental, and other factors closest to the
problem. The chapter also addresses how to collect and
assess data on proximate and underlying causes. It pro-
vides guidance on choosing what to measure, describes
indicators or measures, and guides teams through the
process of ensuring that the data collected are appropri-
ate to the desired measurement. In addition, the chapter
describes the process of designing and implementing
interim changes.
Chapter 5, “Identifying Root Causes,” provides practi-
cal guidance, through workbook questions, on identi-
fying or uncovering the root causes—the systems that
underlie sentinel events—and the interrelationship
of the root causes to one another and to other health
care processes. Systems are explored and described,
including human resources, information management,
environment of care, leadership, communication, and
uncontrollable factors. The chapter also addresses how
to differentiate root causes and contributing factors. The
most frequently occurring root causes identified by orga-
nizations that experienced a medication-related sentinel
event, suicide in a 24-hour care setting, and wrong-site
surgery are provided.
Chapter 6, “Designing and Implementing an Action
Plan for Improvement,” includes practical guidelines on
how to design and implement an action plan—the im-
provement portion of a root cause analysis. During this
stage, an organization identifies risk reduction strategies
and designs and implements improvement strategies to
address underlying systems problems. Characteristics of
an acceptable action plan are provided, as is informa-
tion on how to assess the effectiveness of improvement
efforts. The chapter concludes with information on how
to effectively communicate the results in improvement
initiatives.
10/29/09 5:46:54 PM

Chapter 7, “Tools and Techniques,” presents the
tools and techniques used during root cause analysis.
Each tool profile addresses the purpose of the tool,
the appropriate stage(s) of root cause analysis for the
tool’s use, simple steps for success, and tips for effective
use. Tools and techniques include affinity diagrams,
brainstorming, change analysis, change management,
check sheets, control charts, failure mode and effects
analysis, fishbone diagrams, flowcharts, Gantt
charts, histograms, kaizen, multivoting, operational
definitions, Pareto charts, relations diagrams, scatter
diagrams, SIPOC process maps, stakeholder analysis,
standard work, and value stream mapping. Preceding
the tool descriptions is a discussion of a performance
improvement methodology, Lean Six Sigma, that
incorporates many of these tools.
Chapter 8, “Root Cause Analysis Case Studies from the
Field,” presents root cause analyses that resulted from
real-life incidents at health care organizations. In these
studies, the tools and techniques used to dig down to the
root causes of the events are identified and explained.
Finally, the Glossary provides definitions of key terms
used throughout the book.
A Word About Terminology
The terms patient, individual served, and care recipient
all describe the individual, client, consumer, or resident
who actually receives health care, treatment, and/or
services. The term care includes care, treatment, services,
rehabilitation, habilitation, or other programs instituted
by an organization for individuals served.
Acknowledgments
Joint Commission Resources is grateful to the many
content experts who have contributed to this publica-
tion. They include our editor, Richard J. Croteau, M.D.,
Patient Safety Advisor, Joint Commission International,
and the following Joint Commission and JCI reviewers:
• Maureen Carr, Project Director, Division of Stan-
dards and Survey Methods, The Joint Commission
• Gerard Castro, Project Director, Office of Patient
Safety, The Joint Commission
xiii
00_RCA09_frontmatter.indd 13
Introduction
• Anita Giuntoli, Associate Director, Office of Quality
Monitoring, The Joint Commission
• Robert Katzfey, Field Director, Division of Ac-
creditation and Certification Operations, The Joint
Commission
• Sherri Woods, Sentinel Event Specialist, Office of
Quality Monitoring, The Joint Commsision
• Paul vanOstenberg, Senior Executive Director,
International Accreditation and Standards, JCI
Huge thanks also to our special consultants:
• Diane Rydrych, Assistant Director, Division of
Health Policy, Minnesota Department of Health
• Patrice Spath, Consultant, Brown-Spath & Associ-
ates, and Adjunct Assistant Professor, Department
of Health Services Administration, University of
Alabama, Birmingham
JCR appreciates the valuable contributions made by Rick
Morrow, Lean Six Sigma Master Black Belt, Director
of Business Excellence, The Joint Commission, to the
chapter on tools and techniques. Harold J. Bressler,
General Counsel, The Joint Commission, provided
much-appreciated assistance in clarifying the material
on legal concerns. And finally, JCR would like to thank
writer John McCormack for his help in updating this
book.
References
1. Ornstein C.: Dennis Quaid files suit over drug mishap. Los
Angeles Times, Dec. 7, 2002. http://www.latimes.com/features/
health/la-me-quaid5dec05,1,1883436.story (accessed Oct. 19,
2009).
2. CBS News.com: Dennis Quaid recounts twins’ drug ordeal.
60 Minutes, Aug. 28, 2008. http://www.cbsnews.com/stories/
2008/03/13/60minutes/main3936412_page3.shtml (accessed
Oct. 19, 2009).
3. Miller M., Zhan C.: Pediatric Patient Safety in Hospitals: A
National Picture in 2000. Pediatrics 113:1741–1746, 2004.
4. Peters G., Peters, B.: Medical Error and Patient Safety: Human
Factors in Medicine. Boca Raton, FL: CRC Press, 2007.
5. The Joint Commission: Failure Mode and Effects Analysis:
Proactive Risk Reduction, Second Edition. Oakbrook Terrace,
IL: Joint Commission Resources, 2005.
10/29/09 5:46:54 PM