MHA Keystone Center Holds Tailor-made Root Cause Analysis Workshop

Posted on June 07, 2017

Jim Bagian does cause and effect diagramming during a RCA2 training event. The MHA Keystone Center continued its commitment toward patient safety by holding a workshop tailored to MHA Keystone Center Patient Safety Organization (PSO) members about the root cause analysis (RCA) process. Nearly 60 people attended the May 31 event at the Grand Rapids campus of Grand Valley State University.

The RCA process is essential in healthcare to reduce and eliminate patient harm. It determines what happened and why, then outlines what will be done to prevent it from happening in the future. The training is based on the National Patient Safety Foundation’s RCA²: Improving Root Cause Analyses and Actions to Prevent Harm guidelines and was administered by Jim Bagian, MD, PE, director of the Center for Healthcare Engineering and Patient Safety (CHEPS) and a professor in the Medical School and the College of Engineering at the University of Michigan, Ann Arbor; and Joe DeRosier, PE, program manager, CHEPS. 

The workshop provided the fundamental information and skill development necessary to conduct a robust RCA from start to finish. The majority of the day was spent in small teams working through the RCA process on a simulated event. This provided some practical experience on mapping an event and writing accurate and understandable causal statements. Other activities included developing an initial flow diagram, preparing for staff interviews and documenting the entire procedure. The workshop was structured to equip attendees to begin training their colleagues on what they learned to better standardize the process.

Attendees complete RCA case studies during team exercise.  Attendees of the in-person training will reconvene virtually on a July 17 follow-up coaching webinar, which will give participants an opportunity to share how they have applied the information and tools from the training to their own RCA process.

The MHA Keystone Center PSO began hosting root cause analysis and action (RCA²) trainings in response to member requests. RCAs can also provide crucial lessons learned from adverse events. The events can lead to corrective actions and ultimately eliminate preventable patient and staff harm, which is a primary PSO objective.

Additional RCA² training events will be held Sept. 20 in Livonia and Nov. 29 in Bay Harbor. For more information, contact the MHA Keystone PSO.

Photo Captions:


(Top photo) Jim Bagian does cause and effect diagramming, which consists of brainstorming, putting things in pre-defined categories, discussing potential problems, and coming up with a problem statement.
(Lower photo) Attendees complete RCA case studies during team exercise. 


  • MHA Keystone Center Holds Tailor-made Root Cause Analysis Workshop

Tags: MHA Keystone Center, Patient Safety and Quality, PSO, RCA2

Posted in: Patient Safety & Quality

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