You’re a problem solver in your medical staff or credentialing role. Chances are you’ve been asked to do a root cause analysis (RCA) before, even if you didn’t call it that. Don’t be put off by its painful-sounding name, because it’s a step-by-step way to help you understand and solve problems… and maybe impress your supervisor or colleagues along the way.

How it works
  1. It walks you through looking at an entire system or process
  2. Pinpoints where the failure(s) lie
  3. And finally, helps determine solutions to address those key failure points, or root causes

The root cause is the core issue that sets in motion the causes and effects leading to the problem. Another way to look at it: The highest-level cause of a problem is called the root cause.

RCA describes a spectrum of approaches, tools, and techniques that can be found by the dozens using a simple search. Some approaches are better for general problem solving while some are geared more toward identifying true root causes. By learning about different approaches you’ll have more ways to address a problem.

What it’s not

Now that you’re warming up to RCA, don’t go overboard! RCA takes time and resources when done well, and its use isn’t always necessary. Typical decision making that follows established policy and procedure solves the bulk of issues quickly and completely. However, when negative events become chronic, involve communication or system breakdowns, or result in sentinel events, RCA can be most effective.

It’s also not a blame-game tool. Rather than trying to pinpoint who’s at fault, it focuses on systems, P&Ps, and circumstances that caused individuals or teams to make the decisions they did resulting in the problem. Finally, RCA isn’t an in-the-moment, incident correction tool. Rather, it should occur as a look-back after the immediate situation is resolved or stabilized.

In the credentialing world, the following scenarios reflect appropriateness/inappropriateness for RCA:

YES: A significant number of incomplete temporary privileging files reach the Credentials Committee on a regular basis. The items making files incomplete range from missing signatures to supporting documents that are omitted.

MAYBE: A provider is given and completes an application for medical staff membership and privileges. However, the hospital requires providers to be board certified and she is not, and thus isn’t eligible for appointment.

NO: A provider enrollment specialist’s work volume/output is falling far below that of the two other specialists.

By Industry

RCA methodology is used in all industries, so you can find untold numbers of templates and advice on how to apply it. It started within the movement to total quality management, so it fits well with today’s healthcare quality initiatives.

A simple variation of RCA that works well in credentialing is a method called the 5 Whys Technique. It leans on the use of the people with hands-on experience of the process/problem at hand and works by having them ask “why?” five times to reach the root of a problem. Instead of one solution, the whys seek to find counter-measures, or actions, that aim to prevent the problem from arising again. A simplified example:

The Credentials Committee Chair approaches the VPMA, venting frustration with mistakes being made
on files from the med staff office.

Why: The MSO has allowed some incomplete files to slip through to committee, with the omissions ranging from missing signatures to supporting documents, mainly on temporary privilege requests.

Why: The MSO is understaffed due to a medical leave, while the number of requests for temporary privileges continues steady, causing mistakes to be made and backups to occur.

Why: Temporary privileges for new applicants go through the typical approval process; i.e., there’s no expedited governing body approval process or plan to decrease use of temporary privileges.

Why: Medical staff leaders and administrators have not been educated about why temporary privileges are challenging and are focused only on the need to get the providers working faster.

Why: The culture of the organization has become such that everyone involved in credentialing/privileging drops what they’re doing to accommodate the acute need for the temporary privileges, without consideration of process and risks.

Possible countermeasures: The hospital could strive to develop a culture wherein granting temporary privileges is an exception or special circumstance, not the norm, by investigating why there are continuous holes in a specialty/specialties, ensuring adequate resources exist in the MSO, and educating medical staff leaders and administrators about the process and the risks when privileges are expedited.


Some helpful web sites we found for learning more about RCA

American Society for Quality




For overachievers

Learn about Failure Mode and Effects Analysis (FMEA) and Kaizen—two methods to help minimize the need for RCA in the future.



Joint Commission framework for conducting RCA

IntelliSoft Group’s RCA checklist