Long-Term Care Survey Alert

Root cause analysis is central to QAPI, so practice it now to be sure you’re savvy by the time surveyors start scrutinizing your approach. CMS provides this guide to getting to the root cause:

Problem statement: _______________________________-

One sentence description of event or problem: ____________________________

Why? _____________________________

Why? _____________________________

Why? _____________________________

Why? _____________________________

Why? _____________________________

Root Cause(s) 

1.

2.

3.

To validate root causes, ask the following: If you removed this root cause, would this event or problem have been prevented?

Example: Here is an everyday example of using the Five Whys to determine a root cause: 

Problem statement — Your car gets a flat tire on your way to work. 

1. Why did you get a flat tire? 

• You ran over nails in your garage.

2. Why were there nails on the garage floor? 

• The box of nails on the shelf was wet; the box fell apart and nails fell from the box onto the floor.

 *3. Why was the box of nails wet? 

• There was a leak in the roof and it rained hard last night. (Root cause=leak in the roof) 

*If you stopped here and “solved” the problem by sweeping up the nails, you would have missed the root cause of the problem.

Source: CMS.