12 steps to QAPI: Step 11: Getting to the ‘root’ of the problem

In 1999, the Institute of Medicine Committee on Quality Health Care in America released a report called To Err is Human: Building a Safer Health System. This report concludes that individual accountability is necessary; however, the root of the problem with medical errors or unintentional patient/resident harm is not the healthcare professionals’ competency or good intentions.

The committee’s approach was that the safety of care, defined as freedom from accidental injury, is the responsibility of the system of care, not just the individual providing the care. Imposing reporting requirements and holding people and organizations accountable provides data and is a component of patient/resident safety but do not by themselves make systems safer or processes more efficient.

Patients/residents are safer in all care settings in which specific attention is given to ensuring that care processes are designed to prevent, recognize and quickly recover from events and errors before patient/resident harm occurs. Well-designed systems of care that focus on establishing processes and procedures make it easy to perform tasks correctly and more difficult to perform the task incorrectly. Hidden in errors and near misses is the information needed to design, update and sustain an efficient process to make correct task completion easier.


Root cause analysis (RCA) is a process for intentionally drilling down to the reasons an adverse event occurred or nearly occurred. Nursing homes (NHs) are challenged to reframe their thinking and break down silos to improve care delivery. Healthcare quality is publically reported on Medicare’s Nursing Home Compare, “Business as usual” is not an option for NHs with quality-of-care issues.

As revealed in To Err is Human, sustainable high performance is a result of processes designed with respect to staff weaknesses and strengths that support the intent to do no harm. Except for instances of deliberate abuse, adverse healthcare events or near misses are rarely attributed to a healthcare provider’s purposeful intent to inflict harm. An root cause analysis RCA will identify the causal factors that are the source of the system problems resulting in an adverse event.


Quality Assurance Performance Improvement (QAPI) is a culture change and a fundamental requirement for both high- and low-performing facilities. QAPI at a Glance, details how to get to the “root” of the problem. An RCA describes a systematic process for identifying the contributing causes leading to an undesirable outcome. Armed with the true root cause of the problem, NHs can identify interventions that will more effectively manage or eliminate it. Completing an RCA helps the NH team working to resolve the problem look deeper than the most obvious reasons for the problem or undesirable outcome.

All of the 12 QAPI steps are symbiotic. This process aligns with other QAPI steps, including Step 2: Develop a Deliberate Approach to Teamwork. The collective synergy of a team is the most efficient fuel for moving a systematic problem-solving process forward. QAPI at a Glance presents tools for two problem-solving models, a cause and effect diagram and the Five Whys, which are discussed in detail in this article.

For some PIP (Performance Improvement Project) teams, the basics of the problem statement are included in the PIP charter, established by the Steering Team/Committee. The problem to be solved is part of the charter. System problem-solving begins by defining the problem and crafting a problem statement.


The problem statement indicates the issue(s) to be addressed by describing the problem. It is concise, specific and measurable, specifying who and what is impacted. Input from the problem-solving team confirms mutual understanding of the issue. The Centers for Medicare & Medicaid Services (CMS) provided a tool to help NHs with this process is Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects.  This tool breaks the RCA process into seven steps.

The guidance discusses how to craft the problem statement and includes a sample of an effective problem statement (see helpful hints in the first step). The bottom line of a good problem statement is that every member of the team agrees that the problem statement is effective for that team.


The cause and effect diagram is a structured team process for identifying factors and causes for an event, problem or a near miss. CMS provides a tool called How to Use the Fishbone Tool for Root Cause Analysis.  The fishbone diagram is useful for moderate to difficult problems a team has been tasked to solve. The more complex the problem, issue, event or near miss, the more difficult it can be to identify the true root causes.

Recurring adverse outcomes indicate that more difficult, less obvious root causes are at the heart of the problem. Beginning with the problem statement at the head of the fishbone diagram, the team agrees on the major categories of causes for the problem. The common categories include equipment or supplies; environmental factors; rule or policy; and people or staff. Causal ideas are listed by the team under each category on the fishbone. Responses generated by the team from continuously asking “why?” will help it identify and address the root causes under each of the categories. Part of completing an RCA is planning for the time needed to complete it.

The CMS tool for this process is called Five Whys Tool for Root Cause Analysis can be used to get to the root of a problem. It is a simple problem-solving tool. Getting to the root cause involves listing the contributing factors of an undesirable outcome and asking why. The team’s responses to each “why” question about a contributing factor has to be based on the actual facts of the problem to get to the true underlying causes. This may or may not take asking why five times to get to the true root cause of the problem. Five questions and answers is not a requirement of the process.

Armed with the facts of the event, the team answers the “why” question until it agrees that the root cause has been discovered. Then members can validate by asking whether removing it will prevent a recurrence of the problem. If team members agree that the responses to the validating questions is no, then that is not a root cause. If the team agrees the answer to the validating question is yes, then the team can agree this is a root cause and decide on a corrective intervention. After the team decides on an intervention, a Plan Do Study Act (PDSA) cycle will allow them to implement tested solutions.

Getting to the root of the problem is an essential part of QAPI. All Quality Improvement Organizations (QIOs) can provide NHs with technical assistance for this process. There are webinars and resources on the website for the QIO serving Illinois and Iowa, including a recorded webinar titled “Root Cause Analysis.” A website devoted to QIO activities can be accessed for information about QIOs and to locate each state’s QIO for technical assistance with QAPI and any other CMS-directed improvement initiative. QIOs can help nursing homes with their plans to implement and sustain all of the 12 QAPI steps including Step 12: Take systematic action, which will be the focus of the final article in this series.

Read Steps 1 through 10

12 steps to QAPI: Step 1: Leadership

12 steps to QAPI: Step 2: Teamwork

12 steps of QAPI: Step 3: Self-assessment

12 steps to QAPI: Step 4: Guiding principles

12 steps to QAPI: Step 5: Develop your QAPI plan

12 steps to QAPI: Step 6: Conduct a QAPI Awareness Campaign

12 steps to QAPI: Step 7: Collecting and using data

12 steps to QAPI: Step 8: Identify your gaps and opportunities

12 steps to QAPI: Step 9: Prioritize quality opportunities and charter PIPs

12 steps to QAPI: Step 10: Plan, conduct and document PIPs

Topics: Articles , Executive Leadership , Leadership , Risk Management