Using the RCA process to bring a patient's entire picture into focus

Process improvement experts use root-cause analysis (RCA) to evaluate and identify the reason for the cause of a defect in an effort to isolate the one major area adversely impacting and contributing to a defect and the defect's recurrence.

Identifying the root cause of a chronic illness is one critical process improvement that will positively impact the lives and health of both individuals and communities (and bend the healthcare cost curve down).


When RCA is done successfully, and the root-cause is identified, corrective actions are implemented to correct the root cause issue and thus prevent the defect and its continual recurrence. If a defect's root cause isn't identified, a corrective action is typically created to address symptoms of the defect rather than the actual and primal root cause of the defect and thus the defect continues to persist and recur.

Whether an organization is using LEAN, Six Sigma, TQM or CQI, each of these processes, practices, models and techniques incorporates root cause analysis in the effort to reduce defects and improve outcomes.

Now let's move to the practice of medicine. And let's change "defect" to chronic illness: How often are physicians placed in a situation where they have the time, relationship, trust and information to identify the root cause of a chronic illness? How often are they positioned to truly collaborate with their peers and with their patients? How often are they positioned to move away from a technical fix and toward positioning their patient for an adaptive change based on the root cause of the chronic health issue?

In 2007, David S. Jones, MD, president of the Institute for Functional Medicine, shared as part of his presentation on comprehensive care for complex chronic disease an amazing picture of what can happen when a root cause of a chronic illness is not identified.

In brief, an individual who shows signs of depression sees a psychiatrist and receives a prescription for an SSRI (selective serotonin reuptake inhibitors). This patient also shows signs of hypertension, visits an internist and receives a prescription for an ACE inhibitor (angiotensin-converting enzyme inhibitors).

This individual also suffers from osteoarthritis, consults with an orthopaedic physician, and receives a prescription for an NSAID (nonsteroidal anti-inflammatory drugs). Oh, and this individual is dealing with irritable bowel syndrome and gastroesophageal reflux disease and receives prescriptions from a gastroenterologist for Dicyclomine and an H2 Blocker, respectively.

In this one example, this patient has five diagnoses and is placed on five different prescription medications. He's seeing four different physicians who are not positioned to truly collaborate with one another or with the patient.

At this point no root cause of these health challenges is identified. And no one physician is well-positioned to address the cause once it is determined. As Dr. Jones shares, "Each individual diagnosis becomes a distinct entity unto itself. The patient's whole story never has a chance to be heard and understood in context."

There is no opportunity to identify and address the root cause of these issues (the "underlying mechanisms of disease").

If we are truly to improve healthcare in America (and not just reform it), we need to leverage the best practices of other industries to best position physicians to focus on true healing and patients to truly heal. We need to identify and implement the best practices that will enhance and optimize the healing encounter.

Thomas H. Dahlborg, M.S.M., is executive director of the physician practice True North Health Center, where he focuses on improving growth while ensuring access for the uninsured and the elderly. He has 21 years of experience creating competitive advantages, analyzing customer expectations, and developing and implementing focused and aligned strategic deployment plans. Formerly he served as the chief business strategy officer at Network Health, a comprehensive Medicaid health plan based in Cambridge, Mass.; and was COO of the U.S. Family Health Plan at Martin's Point Health Care in Portland, Maine.