HiQuiPs: Preparation Part 3 – Root Cause Analysis

In Education & Quality Improvement, HiQuiPs by Ahmed TaherLeave a Comment

You have just finished a monthly business meeting with your emergency department (ED) team. One of your colleagues highlighted a recurring issue of the length of time it takes from ordering blood products to administering them in your ED. There is often a long delay in administration for patients who are in acute need.  

You have gathered a team to start working on this quality improvement project. The team has put a project charter together, they have started to engage stakeholders, and created an aim statement as follows: To decrease the time between ordering packed red cells (pRBCs) and administration in the ED by 30% by June 2019. (You can visit our previous posts for details on crafting an effective aim statement!)

At your first team meeting, you decide to perform a root cause analysis to better understand the reasons for the delays. A root cause analysis is a structured approach to identify how or why an incident occurs and to better understand a process.1 It is an essential tool to clearly identify potential contributions to a quality issue. Regardless of which technique is used, it is important to seek interprofessional input, as various providers will have a very different lens through which they see a problem and can provide critical insights into your quality problem.

5 Why’s

There are a variety of approaches that a team can undertake. One simple approach is the “5 Whys”, which is to literally ask yourself “why?” five times in sequence.2 For example:

  • Why is there a delay in administering pRBCs to patients in the ED?
    • Because the pRBCs are delayed in arriving to the ED…
  • Why are pRBCs delayed in arriving to the ED?
    • There is a delay in pRBCs release from the hematology lab…
  • Why is there a delay in pRBCs release from the hematology lab?
    • There is a delay in matching the blood product with the requisition in the lab…
  • Why is there a delay in matching the blood product with the requisition in the lab?
    • The pRBC requisition forms coming from the ED are often missing important information and/or are not legible.

You will notice that your team may not need to ask exactly 5 whys to get to a core issue, or you may need to ask a few more whys – the ultimate goal is to dig deeper into a problem until the team drills down to a manageable modifiable factor.

Fishbone or Ishikawa diagram

ED processes are usually are integrated as part of a wider system, and more sophisticated approaches may be needed such as a fishbone or Ishikawa diagram. This structured approach forces a team to systemically break down and categorize issues into underlying factors, which are grouped under similar headings. The head of the “fish” represents the QI issue (i.e. the problem), while the fish bones are the headings. The headings may be different depending on the project, but can include positions, processes, policies, procedures, equipment, departments, culture, etc.3 The following is an example of a fishbone diagram for delayed antibiotic therapy in sepsis:

Figure 1. Delay to Antibiotic therapy in Sepsis Fishbone diagram. Adapted from from Chartier et al 2018.3

Process mapping

Another structured approach is to utilize process mapping, a multi-stakeholder group exercise to simulate a step-by-step breakdown of a complex process. The specific focus of a process mapping exercise may be looking at sequential flow, responsibilities between parties involved, the relationship between actions, possible bottlenecks, and duplicate or unnecessary steps.4 An important part of process mapping is the team approach where a wide variety of stakeholders are involved in the process mapping exercise to ensure an accurate representation of the nuances around each basic element of the process. For example, to a physician, any given step completed by a nurse may seem simple and straightforward, but there may be a number of sub-steps that they are not even aware of!

The sequence of steps is placed in a diagram with symbols depicting different aspects of the process and their relationships to each other.5 To document the findings of a process mapping exercise, teams often utilize an international standard of symbols in their flow diagrams. The following is an example of commonly used symbols.

Process mapping symbolsFigure 2. Process Mapping Symbols. Adapted from Barach & Johnson 2006.5

Your team has now included a wide variety of stakeholders and as part of your second meeting, they have created a process map (Figure 3). The process map delineated the flow of events from physician assessment to pRBC transfusion. This map was then posted in the ED nursing/physician lounge for front-line providers to comment on and modify as needed. Team members were also assigned different areas of the process map to investigate over the next two weeks. At the following meeting, the front line provider feedback was discussed along with each team member’s findings. It became apparent after this exercise that there were two potential areas to intervene.

pRBCs process map
Figure 3. pRBC ED order to transfusion Process Map

Once the process map is completed, some questions may guide the group in analyzing the process map and generating improvement ideas:5

  • What is the goal of the process?
  • Does the process work as it should?
  • Are there obvious redundancies or complexities?
  • How different is the current process from the ideal process?
  • What are the various factions within the larger group, and how does this division support/hinder more effective processing of patient care?
  • What are the work-arounds to the proscribed process?

Based on your team’s analysis, the first area identified was that the forms completed by physicians were often incomplete and/or illegible. This created a delay when the blood bank clerk sends back the forms, or calls the ED and gets new forms filled out. The second area causing delay was identified to be the time it took to call the hematologist and gain approval based on indications outside of the current transfusion guidelines for the ED. Two teams were set up to tackle each one of these areas accordingly.

Now the team has gone through a lot of preparation steps and has selected appropriate areas to intervene. In our next post we will be discussing different QI intervention methodologies and their use in healthcare such as lean-6-sigma, and PDSA approaches. Stay tuned for next month’s post!

This post was copyedited by Jung-In Choi.

Click here for more articles in the HiQuiPs series!

**UPDATE (November 2020): The HiQuiPs Team is looking for your feedback! Please take 1 minute to answer these three questions – we appreciate the support!**


Peerally M, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf . 2017;26(5):417-422. https://qualitysafety.bmj.com/content/26/5/417.
Williams P. Techniques for root cause analysis. Proc (Bayl Univ Med Cent). 2001;14(2):154-157. [PubMed]
Chartier L, Cheng A, Stang A, Vaillancourt S. Quality improvement primer part 1: Preparing for a quality improvement project in the emergency department. CJEM. 2018;20(1):104-111. [PubMed]
J. Langley G, Moen R, M. Nolan K, W. Nolan T, L. Norman C, P. Provost L. The Improvement Guide. John Wiley & Sons; 2009.
Barach P, Johnson J. Understanding the complexity of redesigning care around the clinical microsystem. Qual Saf Health Care. 2006;15 Suppl 1:i10-6. [PubMed]

Ahmed Taher

Ahmed is an Emergency Physician at University Health Network and Mackenzie Health in Toronto. He completed the Toronto FRCPC Emergency program, and a Masters of Public Health program at Johns Hopkins Bloomberg School of Public Health with certificates in Quality Improvement & Patient Safety, as well as Public Health Informatics.

Cori Atlin

Dr. Cori Atlin is an Emergency Physician at North York General Hospital and Trauma Team Leader at Sunnybrook Health Sciences Centre. She obtained a MSc in System Leadership and Innovation at the University of Toronto. Her interests include trauma, global health, and utilizing health technology to optimize system flow.
Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Lucas Chartier

Dr. Lucas Chartier is an emergency physician and Deputy Medical Director for the University Health Network (UHN) emergency department (ED). He is also UHN's inaugural Medical Director of Quality and Safety, the ED Lead for the Toronto Central Local Health Integration Network (TC LHIN) and the Chair of the Quality Improvement and Patient Safety (QIPS) Committee of the Canadian Association of Emergency Physicians. With training at McGill (MD CM), University of Toronto (FRCPC) and Harvard (MPH), he now tries to spread the QIPS gospel in all the ways possible!