Guidance for Performing Root Cause Analysis (RCA) With Performance Improvement Projects (PIPs) - Template

Sep 12, 2026

Guidance for performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs) describes a structured, team-based method to pinpoint process and system breakdowns behind undesired events. It explains RCA purpose, including identifying root causes, defining corrective actions to prevent recurrence, and using concepts such as timeline reconstruction, contributing factors, and 5 Whys. The process covers chartering scope and team roles, designing and implementing changes, and measuring whether risk decreases.

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Goals of an RCA

Planning

RCA Meeting

Step 3: Describe what happened

Step 4: Identify contributing factors

Step 5: Identify the root causes

Step 6: Design and implement changes

Step 7: Measure the success of the changes

Guidance for Performing Root Cause Analysis (RCA) With Performance Improvement Projects (PIPs) A Root Cause Analysis (RCA) is a structured process conducted by a team of people most familiar with the event and work processes being reviewed. An effective RCA identifies breakdowns in processes and systems, rather than the performance of individuals. • A system is a group or combination of related things or parts that function together. • A process is a systematic sequence of related actions to produce a desired result, often done in a specific order. ■ Processes often span organizational boundaries, linking people, the flow of information, and other resources to create value and deliver results Goals of an RCA: • Identify the root causes of an event that resulted in an undesired outcome. • Develop corrective actions to prevent/eliminate the event from recurring. | Planning | Step 1: Identify the event to be investigated and gather preliminary information.
• What is the problem? (Objective statement of what went wrong.)
• What is the expected outcome? (Objective statement of what will happen when a solution is tested and found to successfully prevent the problem from recurring. Not a solution.)
Step 2: Charter, Facilitator & Team Selection.
Charter includes:
• Scope of the project – a start and end point.
• Expectation for changes to be linked to identified root cause(s) .
RCA Team includes people who:
• Are familiar with the processes and systems associated with the event, including frontline staff.
• Have personal knowledge of the event. (If not available to participate, can contribute through interviews.) | | --- | --- | Notes continued on next page |
RCA Meeting | Step 3: Describe what happened.
• Create a timeline of the event with the sequence of steps leading up to the event.
• Use information gathered in Step 1.
• Include only the facts – not what caused the facts to happen.
• Ensure there is agreement about what happened before moving on to Step 4,
Ask:
■ Does the timeline adequately tell the story of the event? (If not, the timeline may need to be expanded further back in time or expanded to include what happened after the event.)
■ Does each step in the timeline derive directly from the step it precedes? (If not, add missing steps.)
■ Is each step in the timeline pertinent to the incident under investigation?
(Answers may be yes, no, not sure – keep only the yes and not sure steps in the final timeline.)
Step 4: Identify contributing factors.
For each step in the timeline (Step 3), identify the contributing factors (e.g., situations, circumstances, or conditions that collectively increased the likelihood of the incident) . Curiosity leads to discovery.
Ask:
• What was happening at this time that increased the likelihood that the event would occur?
• What might have happened to increase the likelihood the event would occur?
■ Was a recommended practice not followed?
■ Were there any procedure workarounds that may have been used?
■ How did staffing, at the time of the event, impact the eventual outcome?
Remember to consider only the factors that were present and known to those involved at the time – not what was realized after the fact.
Step 5: Identify the root causes.
All incidents have a direct cause. The direct cause is not the root cause. Contributing factors are not root causes.
The root cause is the occurrence or condition that directly produced the incident. Use the 5 Whys to dig deeper into each contributing factor. Use a Cause & Effect diagram to visually represent possible causes.
To determine if the team has truly identified the root cause vs. a contributing factor,
Ask:
• Would the event have occurred if this root cause had not been present?
• Will the problem recur if this cause is corrected or eliminated?
Tip: Staff not following procedures is not a root cause.
Dig deeper

FAQs

What is the main purpose of a Root Cause Analysis (RCA)?

RCA identifies breakdowns in processes and systems rather than focusing on individual performance. It aims to find root causes of undesired outcomes and guide corrective actions to prevent recurrence.

What questions does Step 1 (Planning) require the team to answer?

Step 1 directs the team to state the problem and the expected outcome when a solution is tested, while clarifying scope and what changes must link to identified root causes.

How does the guidance determine whether a factor is a root cause or only a contributing factor?

The guidance distinguishes direct causes from root causes and emphasizes that contributing factors are not root causes. The team tests with questions such as whether the event would have occurred without the suspected root cause and whether the problem will recur if it is corrected.

Sep 12, 2026

Upload by Mack Lee