{"id":4345,"date":"2018-07-24T12:12:21","date_gmt":"2018-07-24T16:12:21","guid":{"rendered":"https:\/\/www.med.unc.edu\/ihqi\/?page_id=4345"},"modified":"2025-10-01T10:27:25","modified_gmt":"2025-10-01T14:27:25","slug":"root-cause-analysis","status":"publish","type":"page","link":"https:\/\/www.med.unc.edu\/ihqi\/resources\/root-cause-analysis\/","title":{"rendered":"Identifying Gaps &amp; Root Causes"},"content":{"rendered":"<p>The identification of gaps and root causes refers to a problem-solving approach to identify the underlying causes for gaps within system processes. This process often takes probing questions and\/or data to identify the event or series of events that create a failure. Common tools include the Fishbone diagram, the 5 Whys, and Failure Mode and Effects Analysis (FMEA). Identifying gaps and root causes is integral part to continuous quality improvement and allows teams to implement long-term solutions that address the root issue rather than just its symptoms.<\/p>\n<h2>Key Steps<\/h2>\n<ul>\n<li>Identify your problem within your process or system.<\/li>\n<li>Use a process map to visualize the overall process or event from start to finish. This will help you make notes of where gaps occur throughout your process.<\/li>\n<li>List out potential causes for these gaps. You can use either a brainstorming activity or diagram (e.g. Fishbone diagram).<\/li>\n<li>From this list of potential causes, identify the root cause using a tool (e.g. 5 Whys). Ideally aim to identify the leading cause that started the chain of events in the process.<\/li>\n<\/ul>\n<h2>Resources to Get Started<\/h2>\n<table style=\"border-collapse: collapse;width: 97.564%;height: 43px\">\n<tbody>\n<tr>\n<td style=\"width: 7.60678%;text-align: center\">\n<p><strong><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-8060\" src=\"https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Read.png\" alt=\"\" width=\"137\" height=\"137\" \/><\/strong><\/p>\n<p><strong>Read<\/strong><\/p>\n<\/td>\n<td style=\"width: 93.2057%\">\n<ul>\n<li><a href=\"https:\/\/asq.org\/quality-resources\/root-cause-analysis\" target=\"_blank\" rel=\"noopener\">What is Root Cause Analysis (RCA)?<\/a> \u2013 This article from the American Society of Quality (ASQ) provides more details about RCA and different approaches to identifying and analyzing root causes in systems and processes.<\/li>\n<li><a href=\"https:\/\/asq.org\/quality-resources\/affinity\" target=\"_blank\" rel=\"noopener\">What is an Affinity Diagram?<\/a> \u2013 This article from ASQ provides tips on how to complete a brainstorming and affinity diagram activity. This technique could be used to help complete an RCA with your team.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 23px\">\n<td style=\"width: 7.60678%;height: 10px;text-align: center\"><strong><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-8065\" src=\"https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Use-2-300x300.png\" alt=\"\" width=\"300\" height=\"300\" srcset=\"https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Use-2-300x300.png 300w, https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Use-2-1024x1024.png 1024w, https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Use-2-150x150.png 150w, https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Use-2-768x768.png 768w, https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Use-2-1536x1536.png 1536w, https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Use-2-2048x2048.png 2048w, https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Use-2-600x600.png 600w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/>Use<\/strong><\/td>\n<td style=\"width: 93.2057%;height: 10px\">\n<ul>\n<li><a href=\"https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/02\/QIToolkit_CauseandEffectDiagram.pdf\" target=\"_blank\" rel=\"noopener\">Cause and Effect Diagram Template<\/a> \u2013 Also know a Fishbone Diagram, this visual tool is used to identify and categorize the potential root causes of a problem<\/li>\n<li><a href=\"https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/02\/QIToolkit_FailureModesandEffectsAnalysis-2.pdf\" target=\"_blank\" rel=\"noopener\">FMEA Template<\/a> \u2013 \u00a0This tool is used to identify, analyze, and prioritize potential failures in a process, ultimately aiming to prevent failures or mitigate their impact.\u00a0<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 33px\">\n<td style=\"width: 7.60678%;height: 33px;text-align: center\"><strong><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-8062\" src=\"https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Watch-2.png\" alt=\"\" width=\"173\" height=\"173\" srcset=\"https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Watch-2.png 173w, https:\/\/www.med.unc.edu\/ihqi\/wp-content\/uploads\/sites\/463\/2022\/01\/Icon-Watch-2-150x150.png 150w\" sizes=\"auto, (max-width: 173px) 100vw, 173px\" \/>Watch<\/strong><\/td>\n<td style=\"width: 93.2057%;height: 33px\">\n<ul>\n<li><a href=\"http:\/\/www.ihi.org\/resources\/Pages\/Tools\/5-Whys-Finding-the-Root-Cause.aspx\" target=\"_blank\" rel=\"noopener\">5 Whys<\/a>\u00a0\u2013 A brief article and video from the Institute for Healthcare Improvement (IHI) describing how to use the 5 whys, which is a technique that identifies the root cause of a problem by repeatedly asking &#8220;why&#8221; five times, each time directing the current &#8220;why&#8221; to the answer of the previous &#8220;why&#8221;.\u00a0 (Video \u2013 1:16)<\/li>\n<li><a href=\"http:\/\/www.ihi.org\/resources\/Pages\/Tools\/CauseandEffectDiagram.aspx\" target=\"_blank\" rel=\"noopener\">Cause and Effect Diagram<\/a>\u00a0(also known as Fishbone Diagram) \u2013 A brief article and video from IHI describing how to use a cause-and-effect diagram (Video \u2013 5:15)<\/li>\n<li><a href=\"http:\/\/www.ihi.org\/resources\/Pages\/Tools\/FailureModesandEffectsAnalysisTool.aspx\" target=\"_blank\" rel=\"noopener\">Failure Modes and Effects Analysis<\/a>\u00a0(FMEA) \u2013 A brief article and video from IHI describing how to use a FMEA (Video \u2013 2:20)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2>Related Concepts<\/h2>\n<ul>\n<li><a href=\"https:\/\/www.med.unc.edu\/ihqi\/resources\/data-visualization-analysis\/\" target=\"_blank\" rel=\"noopener\">Data Visualization &amp; Analysis<\/a> \u2013 Data visualization and analysis is a great way to objectively identify potential gaps that may exist in your process.<\/li>\n<li><a href=\"https:\/\/www.med.unc.edu\/ihqi\/resources\/key-driver-diagram\/\" target=\"_blank\" rel=\"noopener\">Driver Diagram<\/a> \u2013 This tool outlines \u201cdrivers\u201d or key influences that can impact your project. RCA cause be a great way to help identify your drivers<\/li>\n<li><a href=\"https:\/\/www.med.unc.edu\/ihqi\/resources\/process-mapping\/\" target=\"_blank\" rel=\"noopener\">Process Mapping<\/a> \u2013 Mapping out your process can help you understand your overall project and potential gaps that may exists<\/li>\n<li><a href=\"https:\/\/www.med.unc.edu\/ihqi\/resources\/project-charter\/\" target=\"_blank\" rel=\"noopener\">Project Charter<\/a> \u2013 This document which outlines the project purpose and goals often includes the problem statement and potential gaps that may exists<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>The identification of gaps and root causes refers to a problem-solving approach to identify the underlying causes for gaps within system processes. This process often takes probing questions and\/or data to identify the event or series of events that create a failure. Common tools include the Fishbone diagram, the 5 Whys, and Failure Mode and &hellip; <a href=\"https:\/\/www.med.unc.edu\/ihqi\/resources\/root-cause-analysis\/\" aria-label=\"Read more about Identifying Gaps &amp; Root Causes\">Read more<\/a><\/p>\n","protected":false},"author":80925,"featured_media":0,"parent":210,"menu_order":46,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"layout":"","cellInformation":"","apiCallInformation":"","footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-4345","page","type-page","status-publish","hentry","odd"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Identifying Gaps &amp; Root Causes - Institute for Healthcare Quality Improvement<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.med.unc.edu\/ihqi\/resources\/root-cause-analysis\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Identifying Gaps &amp; Root Causes - Institute for Healthcare Quality Improvement\" \/>\n<meta property=\"og:description\" content=\"The identification of gaps and root causes refers to a problem-solving approach to identify the underlying causes for gaps within system processes. 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