The Tools of Quality Improvement

Root Cause Analysis (RCA)

When standards are not met, or an adverse event has occurred, it is necessary to conduct a root cause analysis, which means taking a look back at the sequence of events that led to the discrepancy error. The steps include:

  • Identify the processes involved and keep asking the question, “Why did this happen?” (5 times)
  • Analyze each step in the process using a process map or flow chart to show what happened and compare that to the established protocol or policy then keep asking why the protocol was not followed.
  • Once problem-solving has taken place, make the necessary change in the system using a Plan-Do-Study-Act (PDCA methodology) or similar methodology.


Failure Mode Effects Analysis (FMEA)

FEMA is a risk management technique that looks at current systems to identify an area/process that could potentially cause an adverse event. It is a proactive risk management activity that works by involving all stakeholders to:

  • Identify the patient care processes that make up the system
  • Identify the risk in each process
  • Ask, “What are we doing to reduce the risk?” and take action when gaps are identified.


Proactive Interaction (RADAR)

RADAR defines ways to interact with people so interactions remain interactions and do not escalate into incidents. We strive to be conscious about the process of threat assessment so we can maintain our safety and the safety of others and to be aware of how we may appear to be threatening to others. RADAR stands for:

  • Recognize: Use all of your senses. RADAR works by being aware of your surroundings.
  • Assess: Assess what is happening to everyone, starting with yourself and the environment.
  • Decide: Decide what to do after you have recognized and assessed.
  • Action: The decision comes to life.
  • Results: Evaluate the results. Did you achieve the goals of your action(s)? 


Plan-Do-Check-Act Cycle (PDCA)

PCDA is a dynamic cycle that could be implemented for any process within the organization. It combines planning, implementing, controlling and continual improvement within the realization processes.

  • Plan: Recognize an opportunity and plan a change.
  • Do: (select an option for improvement, initiate improvement, and establish success measurements)Test the change. Carry out a small-scale study.
  • Check: (measure performance)Study. Review the test, analyze the results and identify what you’ve learned.
  • Act: (modify plan for improvement as necessary to meet established success measurements) Take action based on what you learned in the Check Step: If the change did not work, then go through the cycle again with a different plan.  If you were successful, incorporate what you learned from the test into wider changes. Use what you’ve learned to plan new improvements, beginning the cycle again.


For more information about our quality initiatives contact:
Michael Redmond, senior vice president 
603.547.3311, ext. 1479 

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