Root Cause: A Healthy Process

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Our clients face many challenging life situations – frailty or disability. Our care managers and caregivers have the knowledge, expertise and experience to help, no matter what the challenge.

Unavoidably, our clients and staff have complex interactions, sometimes with outcomes we had not expected or intended. So that we can learn from, and avoid repeating, the inevitable problems and mistakes that arise from theses interactions, we use a process we call “Root Cause Analysis”.

Its purpose is straightforward: to get better at what we do through rational analysis. When something goes awry, we seek ways to improve our practices, rather than focus on blaming.

1. We recognize when something has occurred that raises a non-routine concern, warranting discussion.

2. We arrange a meeting as soon as possible with the key staff who are already involved, or should be.

3. Together they define the issue in need of review.

4. The group asks “why” (for example, why something happened; or did not; or what options may have existed; or what decision was made, when, why) and keeps asking until they agree why the outcome, event, omission or concern occurred – i.e., what was the root cause.

5. Then, and only then, does the group consider what change(s) are needed to minimize the risk of that outcome happening again.

6. Once we’ve agreed on the change(s) needed, we implement them in our practice and monitor their efficacy.

Root Cause Analysis is a growth process for a healthy organization.

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