Root Cause Analysis (RCA) Resource Center

Four-Step RCA/CA Process

Step 1: Form and Focus the Team

  • If the problem has been around for a while, it is probably not easy to find and fix. A team approach pools the experience and expertise of all members to focus on and solve the problem.
  • A Problem Statement communicates the scope of the problem, establishes a common understanding of the problem among all team members and focuses the team on the task at hand.

Step 2: Find the Root Cause

  • It takes detective work to find the root of the problem.
  • Think of root cause analysis as “problem-finding”; once the real problem (the root cause) has been found, the solution to the problem is often obvious.
  • Follow the trail of evidence; the evidence (data) will point the way from the symptoms to the root cause of the problem.

Step 3: Fix the Root Cause

  • Once the root cause or causes have been found, typically one or more potential solutions will become apparent as well.
  • The next job is to select the best solution or combination of solutions that will lead to a robust yet cost-effective solution.
  • Screen solution candidates by testing the practicality, feasibility, and cost-effectiveness of the solution. If the solution candidate fails those tests, move on to more promising solution candidates.
  • When many solution candidates are still in contention, the use of decision-making matrices can help guide the objective decision.
  • Note: Sometimes, the best solution combines aspects from two or more (preliminary) solutions.
  • Once the solution is approved for implementation, it is time to create an action plan.
    • Action plans can be simple or complex.
    • A simple action plan merely documents what needs to be done, who will do it, and by when it will be completed.
    • On the other hand, a complex action plan involves more thorough planning and documentation of the implementation process and may include the use of project management tools such as Activity Plans, PERT Charts and Gantt Charts.

Step 4: Finalize Solutions

  • Once the solution is in place, validate the solution by checking to make sure the desired outcomes have been realized.
  • Update all related documentation.
  • Update Quality Systems, Control Plans, related FMEAs and Operating Procedures.
  • Adjust audit systems and schedules to ensure the gains are held.
  • And share lessons learned to multiply the gains.