Root Cause Analysis in the Time of COVID-19:

In Education & Quality Improvement, Featured Education Innovations (FEI), HiQuiPs by Tayler YoungLeave a Comment

You are midway through a busy rapid response shift where you have noticed an increased response time of the hospital’s intubating teams to decompensating patients. Over the last few months, the COVID-19 pandemic has prompted restructuring of the use of many spaces to accommodate the influx of patients. You understand that the system is overwhelmed but you are optimistic that you can optimize the interprofessional team’s response times. This sets off a new QI project that you are excited about! After some asynchronous work with the team, you decide on a project charter and pick an appropriate aim statement. You are now left with the root cause analysis (RCA) meeting where many stakeholders will be present to contribute ideas. But this RCA meeting will be held virtually – how do you go about this?! 

Welcome back to another HiQuiPs post! During the pandemic many of us have had to adapt our previously in-person meetings to virtual settings. It is no easy feat, especially when meetings such as for Root Cause Analysis (RCAs) require extensive real-time collaboration. 

Reflecting on previous virtual meetings that didn’t go too well, you use the 5 whys mental exercise to think of contributory elements. 

Figure 1. 5 Whys  – Virtual meeting communication issues 

You may be used to RCA meetings with white boards, sticky notes or walk arounds. With the ongoing need for a virtual approach, how do you best optimize them? 

Currently, there is no literature on best practices for optimizing virtual collaboration, and specifically, when performing an RCA.

Here are some tips to get you started:

  1. Set a Moderator

Having a person who leads the group by organizing team meetings, checking in with team members, moderating discussion, and setting the meeting agenda is crucial to ensure that a project continues to move forward. The moderator should ensure that they are able to use the online meeting tools effectively. They should also have the contact of the local IT person. If it is a very large meeting, it may be helpful to have an IT person on call/present, or an assigned attendee to take over muting/unmuting, breakout, and other functions. 

  1. Fractionate and Communicate

For virtual meetings, pre-meeting preparation becomes even more important to allow discussions to run smoothly. A period of asynchronous work may be completed prior to the meeting. You can consider organizing team members by their roles on the intubating team to discuss their workflows or other pre-assigned questions. 
To host these pre-meeting discussions between groups of your team, a platform where the entire team and subgroups can communicate, share, and access files is useful. One example is Slack, through which your team can discuss details and share files within the overarching Team “channel” and in their own group’s “channel” chat. Other applications with similar features are Google Chat or the Microsoft Teams chat function. The platforms differ in scalability and some offer paid options depending on your team’s needs. A brief introduction on how to use the chosen communication platform should be sent to the participants in case they are not familiar with it.

  1. Meeting Logistics

For the first team meeting, outlining a quick review of the meeting tool utilization and meeting etiquette may be beneficial. Will you be using raising hand functions, the tool chat, sharing screens, group voting, etc.? Are participants encouraged to keep their video on and their microphones off? Letting your participants know what to expect may reduce confusion later on.

There is also a ’break-out’ room function with services such as Zoom or Microsoft Teams. This way, meeting structure can be maintained and may enable concurrent interprofessional or role based discussions. When the breakout time ends, all meeting members are sent back to the main meeting where the designated spokespeople can present their group’s thoughts. Please see the hyperlinks for tutorials on creating breakout rooms for Zoom and Microsoft Teams.

  1. Utilizing Apps to Support Engagement

One function that can be missing during virtual RCA meetings compared to in-person is the whiteboard / sticky notes that some find helpful for creating Fishbone diagrams and for process mapping. Miro is an online whiteboard built for collaboration. With Miro, team members can video chat while using the whiteboard space to directly share images, videos, and documents and utilize virtual sticky notes and chart templates. Available templates include 5 Whys, Fishbone diagram, Concept maps, and other tools such as a Stakeholder Analysis template. Miro can also be integrated with other apps such as Microsoft Teams and Slack. 

Another virtual whiteboard application is Google Jamboard. Google Jamboard works similarly to Miro where users can collaborate together to share content and collaborate using virtual sticky notes. Google Jamboard does not contain templates like Miro, but Google Jamboard does have free drawing functions with pens and shapes, allowing users to more freely create their own charts and maps. Miro and Google Jamboard differ in scale and pricing depending on the organization’s needs.

  1. Get Creative

While there are more online apps to support RCA group work, if they are not for you and you want a ‘low tech’ way of doing sticky notes and other types of brainstorming (for smaller groups) consider sharing your computer screen and working off of Microsoft PowerPoint or other similar tools. 

Get creative and engage your team members! An engaging virtual meeting is still possible. You have cut down didactic work by doing asynchronous pre work. Now you can seamlessly share multimedia, create polls, engage lively debate and discussion. You can also take group pictures and share them on social media!

Figure 2. 5 Tips to improve virtual root cause analysis meetings 


Now that you are equipped with these pearls in your back pocket, you decide on several key questions for groups to answer on Slack pre-meeting. You also have a Google doc to share all of your group documents integrated with Slack. The meeting starts off with some introductions and smoothly goes between breakout session discussions and polls while you use Miro for brainstorming. Your team creates a great Fishbone and driver diagram highlighting key areas of intervention for your next meeting! 

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*The applications mentioned are for illustrative purposes. The authors have no conflicts of interest to declare.

Senior Editor: Dr. Lucas Chartier (@chartierlucas)

This post was copyedited by Tiffany Tse.

Tayler Young

Tayler Young is a fourth-year medical student at the University of Ottawa. She is interested in quality improvement and patient safety, mentorship, and medical education. Outside of medicine, she enjoys ice hockey, field hockey, and embroidery.

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.

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!