Root-cause analysis is useful for ED problems

An analysis tool commonly used for investigating adverse events and other process errors in health care can prove useful in the ED as well, say experts who have seen it used to address long wait times and similar problems.

The technique is called root-cause analysis (RCA), and chances are you’ve heard the term tossed around, but it’s not as likely that you’ve actually employed it in the ED.

Most health care professionals are familiar with RCAs being performed after unexpected deaths or similar events in health care, partly because those are situations in which an RCA sometimes is required by the Joint Commission on Accreditation of Healthcare Organizations.

But ED managers also should take advantage of the benefits offered by RCAs, says Michael J. Williams, MPA, HSA, president of The Abaris Group, an ED consulting group in Walnut Creek, CA.

Williams says RCAs are "very potent tools" that can help you zero in on the true source of problems in your ED rather than addressing the surface.

"Often we see EDs attempt to solve the wrong problem," he explains. "We see intelligent, bright people trying to throw darts at the problem, applying the latest whim of best practices and hoping that helps, without ever finding the root cause. Then you spin your wheels a lot, get frustrated, and a lot of organizations just give up on change initiatives," Williams notes.

An RCA can help avoid that futility by directing all your efforts at the real cause of the problem. The most obvious opportunities to use RCA in the ED include long wait times and slow flow through, he contends. Revenue management is another possibility.

"Another big area is customer service," Williams continues. "We hear from a lot of hospitals that think they’re providing good customer service but can’t understand why their satisfaction ratings won’t move up. A good RCA can help identify the roadblocks."

RCA drills deep for answers

RCAs can identify factors that you might not find otherwise, says Howard Peth, MD, JD, assistant professor of emergency medicine at the University of Missouri School of Medicine in Columbia, and chair of the legal committee for the American College of Emergency Physicians in Irving, TX.

Peth notes that the whole point of an RCA, rather than a typical analysis, is to drill down deep enough to find the issues that might go unnoticed if you stop at just a broader explanation of the cause.

"If you’re looking at why you’re overcrowded, you might be able to figure out on your own that you’re not moving patients out to the other floors," he says. "Or maybe you’ve figured out that physicians aren’t discharging patients fast enough."

That’s a good start, but it’s not enough to help you really address the problem, Peth says. "A root-cause analysis will take you a lot further and find the reason for those problems," he says.

ED managers probably will not be able to conduct an RCA without help, Williams notes. RCAs are complex and require certain analytical skills that you can’t learn on the fly, he says.

In most cases, it would not be worth an ED manager’s time to start from scratch in learning how to do an RCA, Williams adds.

Consultants are one option, but you also can call on your peer review or quality improvement department, where RCA is a standard tool and where there are experts who can help you conduct one in the ED, he says. The risk management department is another area where you will find people with the right skills.

Might need several RCAs

A good RCA will require the involvement of the chief of staff and other senior leaders in the hospital, Peth notes.

It may be necessary to conduct several RCAs and combine the results, says Kenneth A. Hirsch, MD, PhD, a practicing psychiatrist and director of Medical Risk Management Associates, a consulting firm in Honolulu. His consulting firm specializes in assisting providers with RCAs and other investigations.

"If you’re looking at overcrowding, you might need to study entry into the system, initial screening, lab work, disposition, and so on," he says. "Each one of those might require a separate root-cause analysis, with each one looking at the individual steps involved with each process."

The essence of an RCA is never accepting a simple explanation for anything. When you think you have found why a particular problem exists, the RCA demands that you dig a little deeper, Hirsch points out.

Simply put, much of the RCA involves asking the question "why?" over and over again, until you get so far down into the process that you cannot obtain a meaningful answer, he adds.

"At each step, you also have to ask if there are leadership decisions that have contributed to this problem," he explains. "If you don’t feel comfortable asking or answering that question, then you’ve identified a major problem."


For more information on using root-cause analysis in the ED, contact:

  • Kenneth A. Hirsch, MD, PhD, Director of Medical Risk Management Associates, Honolulu. Phone: (703) 391-7244. Web site:
  • Howard Peth, MD, JD, Assistant Professor of Emergency Medicine, University of Missouri-Columbia, Columbia, MO 65211-4190. Phone: (573) 882-6487.
  • Michael J. Williams, MPA, HSA, President, The Abaris Group, 700 Ygnacio Valley Road, Suite 270, Walnut Creek, CA 94596. Phone: (925) 933-0911. E-mail: