MHA Keystone Center Continues Focus on Root Cause Analysis

Posted on June 22, 2018

The MHA Keystone Center Patient Safety Organization (PSO) has focused heavily this year on collecting root cause analyses (RCAs), incident reports and near misses from all MHA Keystone Center PSO member organizations. The MHA Board of Trustees set a goal for the 2017-2018 program year to increase RCA submissions from MHA Keystone Center PSO member hospitals to 60 percent. The goal was met by mid-June.  

Overall, the purpose of the efforts was to share lessons learned by MHA Keystone Center PSO members to increase process improvement and prevent future patient and staff harm.

As part of the MHA Keystone Center PSO’s continued focus on patient safety, the center held a root cause analysis and action (RCA²) training June 20 in Kalamazoo. More than 60 people from 18 hospitals attended the event, which showed participants how to improve the RCA process from start to finish within their organizations and provided lessons learned from anonymously reported adverse events.

The workshop provided an opportunity to work in small groups through a simulated event, which consisted of developing an initial flow diagram, preparing for staff interviews, and learning how to document and standardize the RCA² process. The training is based on the National Patient Safety Foundation’s RCA²: Improving Root Cause Analyses and Actions to Prevent Harm guidelines, which is available by registering for free basic access on the Institute for Healthcare Improvement website.

For more information, contact the MHA Keystone Center PSO.



Tags: patient safety, rca, adverse events, MHA Keystone Center PSO, root cause analysis, National Patient Safety Foundation, Institute for Healthcare Improvement

Posted in: Patient Safety & Quality

MHA Updates Delivered to You

Subscribe to the MHA Monday Report weekly newsletter or our podcast, the MiCare Champion Cast, to keep informed about the latest healthcare news and events in Michigan.

MHA Monday Report
Contact us to subscribe

MiCare Champion Cast
iTunes | SoundCloud


Media Inquiries

Contact the MHA at
(517) 703-8601

Read the MHA policy on publication via MHA media.

MHA 100 Year Anniversary

Watch the video »