Managing the scope and impact of root cause analysis recommendations

J Health Organ Manag. 2008;22(6):569-85. doi: 10.1108/14777260810916551.


Purpose: Increased public awareness of clinical failure and rising levels of litigation are spurring health policy makers in industrialized countries to mandate that clinicians report and investigate clinical errors and near misses. This paper seeks to understand the value of root cause analysis (RCA) recommendations for practice improvement purposes. The paper presents an analysis of interviews with nine senior health managers who were asked about their views on RCA as practice improvement method.

Design/methodology/approach: Interview data were collected as part of a multi-method evaluation consultancy project investigating a local Health Safety Improvement Program. The interview data were discourse analysed and arranged into over-arching themes.

Findings: The analysis reveals rather negative views of the improvement potential of RCA: RCA is subject to too many constraints to be able to produce valuable recommendations; RCA recommendations: are perceived to be of "variable quality"; generate considerable extra work for senior management to do with vetting RCA recommendations; are experienced as contributing in only a limited way to organizational and practice improvement.

Research limitations/implications: This study focuses on nine interviewees only and presents an analysis of single (not multiple) interviews. However, these nine interviewees fulfil crucial roles in implementing clinical practice improvement initiatives in their respective geographic areas.

Practical implications: The findings suggest that RCA requires much time and negotiation, and that the recommendations produced may not live up to the philosophy of clinical practice improvement's expectations. It may be necessary to reorient the expectations of the power of RCA, or accept that RCA produces communication about clinical processes that would otherwise not have taken place, and whose effects may not be registering for some time to come.

Originality/value: Besides drawing out the implications for RCA as investigative practice, the analysis argues that interviewees' responses harbour indications to suggest that these officials are finding themselves engaged in increasing levels of communicative and emotional labour, in having to manage and compensate for the ambiguities, incommensurabilities and conflicting goals inscribed into "post-bureaucratic" initiatives such as RCA.

MeSH terms

  • Attitude of Health Personnel*
  • Health Facility Administrators / psychology*
  • Health Services Research
  • Humans
  • Interviews as Topic
  • Medical Errors* / prevention & control
  • New South Wales
  • Risk Management / methods*
  • Total Quality Management / methods*