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The content explains common uses across accident investigation, risk analysis, process improvement, change management, and quality control, then links RCA applications to sales, manufacturing, safety, operations, healthcare, projects, environmental incidents, and performance audits. It contrasts RCA expectations in public-sector auditing, reviews typical performance audit deficiencies, and frames the core “Why?” inquiry. Finally, it outlines how RCA strengthens recommendations, clarifies findings, and supports lasting solutions.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":11,"@type":70,"position":76},"https://docshare.wps.com/template/presentations/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/root-cause-analysis-for-legislative-auditors-september-2014/243838/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/root-cause-analysis-for-legislative-auditors-september-2014/243838.png","ImageObject",442,249,{"name":88,"@type":89},"Berry Peter","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-19","2026-09-12",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is Root Cause Analysis (RCA) in this presentation?","Question",{"text":108,"@type":109},"RCA is an approach to understand why something happened or how a situation developed, using a range of qualitative and quantitative tools rather than one single methodology.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"In what situations is RCA commonly applied?",{"text":113,"@type":109},"It is used across settings such as accident investigation, risk analysis, business process improvement, change management, and quality control, with examples spanning sales, manufacturing downtime, safety injuries, healthcare medication errors, projects, environmental failures, and performance audits.",{"name":115,"@type":106,"acceptedAnswer":116},"What are common performance audit findings that RCA helps investigate?",{"text":117,"@type":109},"Findings include non-compliance with rules and policies, results not achieved, unmanaged risks, strategies not followed, uncoordinated actions, unclear roles, unsupported decisions, and lack of oversight.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},243838,1791735861,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":8,"category_name":11,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":141},1374402524268,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","ROOT CAUSE ANALYSIS  \nFOR LEGISLATIVE AUDITORS  \nSeptember 2014  \nPresentation to the Pacific North West InterGovernmental Audit Forum  \nWhat is Root Cause Analysis (RCA)?  \n2  \n􀂅 An approach to understanding why something happened or how a situation developed  \n􀂅 A body of qualitative and quantitative tools and techniques, not a single methodology  \n􀂅 Applied in a range of settings including accident investigation, risk analysis, business process improvement, change management, and quality control  \n􀂅 Used extensively in manufacturing and private sector  \nCommon Applications of RCA  \n3  \n􀂅 Sales: Why did we lose that sale?  \n􀂅 Manufacturing: Why did we have down time?  \n􀂅 Safety: Why did we have that injury?  \n􀂅 Operations: Why did we have that delay?  \n􀂅 Healthcare: Why did that medication error occur?  \n􀂅 Projects: Why did the project take too long?  \n􀂅 Environmental: Why did the tailing pond collapse?  \n􀂅 Performance Audit: Why is the legislation not being complied with? Why is the organization not meeting its mandate?  \nVarious Tools and Techniques Applied in the Private Sector  \n4  \n􀂅 SIPOC mapping (Suppliers, Inputs, Processes, Outputs, Customers)  \n􀂅 FMEA (Failure Mode and Effects Analysis)  \n􀂅 Kipling’s questioning technique (What, Why, When, Where, How, Who)  \n􀂅 The “Five Whys” questioning technique  \n􀂅 Cause mapping  \n􀂅 Fish bone (Ishikawa) diagrams  \n􀂅 Flowcharting  \n􀂅 Pareto charts.  \nRCA and Public Sector Auditing  \n5  \n􀂅 RCA is not required by Canadian auditing standards  \n􀂅 Some argue it is the responsibility of entity management  \n􀂅 Some argue it is the responsibility of Public Accounts Committees  \n􀂅 So why bother?  \nCommon Performance Audit Findings  \n6  \n􀂅 Rules and policies not complied with  \n􀂅 Results not achieved  \n􀂅 Risks not managed  \n􀂅 Strategies not followed  \n􀂅 Actions not coordinated  \n􀂅 Roles not clear  \n􀂅 Decisions not supported  \n􀂅 Oversight not in place  \nThe Burning Question: Why?  \n7  \n􀂅 Why are entities not in compliance?  \n􀂅 Why are intended results not achieved?  \n􀂅 Why are risks not managed?  \n􀂅 Why are strategies not followed?  \n􀂅 Why isn’t oversight occurring?  \n􀂅 Why…? Why…? Why…?  \n􀂅 Analyzing the underlying causes of observed audit deficiencies helps to delve down below the surface, beyond the symptom, to answer these Why questions  \nThe Value-Added Proposition  \n8  \n􀂅 Root cause analysis can significantly increase the impact of public sector performance audits by…  \n􀂆 Informing recommendations that address the cause of deficiencies, thereby leading to lasting solutions  \n􀂆 Providing insight and explanation for audit findings  \n“The formulation of the problem is often more essential than its solution.”  \nAlbert Einstein","cbCaibvv9AN5fjEp","https://ap.wps.com/l/cbCaibvv9AN5fjEp","pdf",1741576,23,"English","# What is Root Cause Analysis (RCA)?\n## Common Applications of RCA\n# Various Tools and Techniques Applied in the Private Sector\n## RCA and Public Sector Auditing\n# Common Performance Audit Findings\n## The Burning Question: Why?\n# The Value-Added Proposition","[{\"question\":\"What is Root Cause Analysis (RCA) in this presentation?\",\"answer\":\"RCA is an approach to understand why something happened or how a situation developed, using a range of qualitative and quantitative tools rather than one single methodology.\"},{\"question\":\"In what situations is RCA commonly applied?\",\"answer\":\"It is used across settings such as accident investigation, risk analysis, business process improvement, change management, and quality control, with examples spanning sales, manufacturing downtime, safety injuries, healthcare medication errors, projects, environmental failures, and performance audits.\"},{\"question\":\"What are common performance audit findings that RCA helps investigate?\",\"answer\":\"Findings include non-compliance with rules and policies, results not achieved, unmanaged risks, strategies not followed, uncoordinated actions, unclear roles, unsupported decisions, and lack of oversight.\"}]","ROOT CAUSE ANALYSIS - FOR LEGISLATIVE AUDITORS - September 2014 | PDF",1789209207,8]