Using Root Cause Analysis to Achieve Organizational Goals

By Kim Smiley

The Commonwealth Fund’s healthcare improvement website ( provides case studies of medical facilities that have been improving various performance measures.   One of these cases involves Holland Hospital, in Michigan, which has improved its pneumonia process-of-care over the last five years and is now in the top three percent of hospitals in the U.S. for these core measures.

The process for establishing goals and implementing process improvements to meet those goals is the same process that is used for Cause Mapping.  I’d like to highlight some of the tips from Holland Hospital’s success.  (You can read the whole case study at

Establish a team to develop and work towards goals:  The hospital’s “core measures leadership team” contains physicians, clinical directors and other leaders to ensure buy-in from those closest to the work and management.  The team meets to review noncompliant cases (called “opportunities for improvement”) on a monthly basis.  Additionally, the hospital created a respiratory disease core measure team which developed improvement strategies specific to the pneumonia core measures.

Focus on the system, not on blame: According to the hospital’s director of quality and risk: “the hospital’s patient safety culture means being blame-free. Unless the case is egregious, we assume mistakes occurred because the established care process failed our staff and/or physicians.”  Rather than focusing energy on assigning blame, the team focuses on improving systems to reduce the occurrence of similar incidents, improving the core measures performance for all staff members, not just the ones involved in the noncompliant cases.  As an example, the hospital increased screening for the pneumonia vaccine by reprogramming the electronic nursing record to require an answer to

Get everyone involved: If performance goals are met, and money is available, a bonus pool is established for all full-time employees (even those not directly involved in patient care), except hospital executives.  If the performance goals are not met, no bonus money is distributed.

Adjust responsibilities when necessary: The hospital discovered some difficulties with one measure – taking a blood culture prior to giving antibiotics.  The team discovered that there was a delay in taking the blood culture because a phlebotomist had to be called into the emergency room.  The team also discovered delays in administering antibiotics when a patient was transferred to another unit from the emergency department. A process change resolved these difficulties.  Emergency room nurses now take the blood culture (contacting a phlebotomist assigned to the emergency department if necessary) and administer the first dose of antibiotics before the patient leaves the emergency department.