Grant Case Study: Taking Action to Improve Root Cause Analysis

The Doctors Company Foundation funds creation of new root cause analysis guidelines to prevent adverse events

Grantee Profile

The National Patient Safety Foundation (NPSF) is a non-profit organization dedicated to improving patient safety through their vision to create a world where patients and those who care for them are free from harm.


  • The Doctors Company Foundation funded a $138,786 grant for NPSF. This grant enabled the development of new consensus practices for root cause analysis (RCA), a tool used across hospital and healthcare systems to identify causes of errors and harm and to design strategies to prevent future occurrences.
  • A second grant from The Doctors Company Foundation also funded a series of webinars to educate healthcare leaders on how to implement these guidelines and take action in their organizations to mitigate risk.
  • Nearly 11,000 healthcare professionals have been educated on how to better investigate errors, adverse events, and near-misses and implement the new guidelines in their organizations.
  • Over 20 organizations have endorsed the guidelines, agreeing to implement the changes.

The Challenge: Addressing Varied RCA Performance

Some organizations do an excellent job in performing RCA and implementing improvements as a result of the findings. However, many organizations struggle to have a robust RCA process and to implement actions that lead to future risk mitigation.

Improving RCA to Prevent Adverse Events

NPSF looked to address the current state of highly variable and inconsistent RCA practices and approaches. It realized that if healthcare organizations had a more standardized framework, they could improve the way they investigate errors, adverse events, and near-misses.

“The foundation for this work was established because there still continues to be unacceptable levels of preventable harm in medicine,” said Patricia McGaffigan, chief operating officer and senior vice president of programs at NPSF. “Without systematic application of RCA practices that adequately investigate why things went wrong—and why things went right—organizations cannot create action plans that will minimize the risk of recurrence and create and sustain meaningful change.”

Through the grant, The Doctors Company Foundation enabled the NPSF to develop “RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.” The guidelines were the result of two full-day sessions of a small working group comprised of leaders in patient safety, risk management, adverse event investigation, patient advocacy, and RCA.

“The National Patient Safety Foundation has a longstanding relationship with The Doctors Company Foundation, and we knew we could look to them as a trusted partner to continue to make our vision for patient safety come to life,” McGaffigan said. “Our new guidelines offer the structure and framework for organizations to not only conduct better RCAs, but to take better ‘actions’ after RCA—which is why the guidelines are called RCA squared—that will create sustainable and meaningful change in patient safety practice and patient care.”

Sustainable, Systems-Based Actions

During each of the convening sessions, RCA and risk/safety leaders framed a systematic, thoughtful approach to produce successful practices that would help RCA teams identify and implement sustainable, systems-based actions to improve safety of care. To facilitate implementation, the guidelines include successful practices and tools for conducting RCAs, metrics to assess success, strategies to overcome barriers, and an implementation plan for organizations.

James P. Bagian, MD, PE, member of the Board of Governors of The Doctors Company, co-chaired the working group along with Doug Bonacum. Dr. Bagian contributed knowledge from his background in safety as both an astronaut and physician to improve systems issues with proven risk reduction strategies from the aeronautical and submariner industries.

McGaffigan also noted that one of the key messages in the report centered on using a risk-based approach rather than a harm-based approach to prioritize safety events, hazards, and vulnerabilities. Most RCAs are conducted on rare occurrences of severe harm only.

The guidelines also help healthcare organizations focus on building a culture of transparency, according to Joellen Huebner, ‎program manager, Lucian Leape Institute, Grants, and Special Projects, NPSF.

“While the vast majority of error and harm occur because of systems issues, the sharing of learnings from RCA is also critically important to enable sustained change,” Huebner said. “People usually struggle to disseminate learnings from RCA not only among their teams but also with patients and families. The guidelines offer the structures, steps for timing, and tools to make that change that can prevent errors and patient harm in the future.”

Spreading the Word

After publication of the guidelines in June 2015, NPSF held a webinar funded by The Doctors Company Foundation to share key findings and recommendations. Over 7,000 attendees tuned in, making it the largest webinar in NPSF history. Additionally, over 20 organizations endorsed the guidelines, agreeing to implement the changes.

“We were so very excited about the overwhelming response and interest from the healthcare community about this new and important perspective,” McGaffigan said. “And immediately after the webcast, we started receiving daily inquiries from patient safety and risk management leaders, regulatory and licensing bodies, and healthcare professionals asking for specific help and resources to help them to implement the changes in their own organizations.”

Due to the success of this first webinar, The Doctors Company Foundation provided additional funding to support the sharing of best practices around RCA2 implementation.

With this second round of funding, NPSF hosted four separate webcasts featuring healthcare delivery organizations that were applying and implementing RCA2, highlighting best practices and challenges in implementation. These no-charge webinars were attended by nearly 1,000 viewers each, representing a diverse set of healthcare participants including patient safety and quality employees, clinical staff, executives, and medical malpractice representatives.

“Some of these organizations discussed how much the risk-based system has positively impacted the safety of patients,” McGaffigan said. “They’re able to look at risk and identify potential impact for the implementation of new systems before adverse events actually happen. Thanks to the support of The Doctors Company Foundation, they are seeing their teams preventing patient harm and learning from near-misses and close calls to save lives.”