Resource Location: https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/guidanceforrca.pdf
Overview: A Root Cause Analysis (RCA) is a structured, facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. The RCA process provides a way to identify breakdowns in processes and systems that contributed to the event and how to prevent future events.
The purpose of a RCA is to find out what happened, why it happened, and determine what changes need to be made. It can be an early step in a PIP, helping to identify what needs to be changed to improve performance.
Once you have identified changes that need to be made, the steps you will follow are those you would use in any type of PIP.
Use this Step-by-Step Guide for Performing Root Cause Analysis with Performance Improvement Teams to investigate events in your facility (e.g., adverse event, incident, near miss, complaint).
Download this fillable RCA PIP Team Template to track progress toward process improvements.
NOTE: Facilities accredited by the Joint Commission or in states
with regulations governing completion of RCAs should refer to those requirements to ensure all necessary steps are followed.