Diagnose Root Causes with an Equity Lens
What does it mean to diagnose root causes with an equity lens, and why is it important?
A Root Cause Analysis (RCA) helps organizations understand why undesirable outcomes occur so they can address root issues, not just symptoms. When applied with an equity and anti-racist lens, an RCA goes further, asking how structural factors like racism, classism, and ableism shape access to care and patient experiences, and what power dynamics within the healthcare system reinforce inequities. By centering patients living with the inequities being addressed in the analysis, teams can identify and address the true root causes of inequities rather than unintentionally reinforcing them.
When should I diagnose root causes with an equity lens?
Conduct an RCA as soon as possible after your team has identified a health equity focus. Revisit RCA results and update it with the input of key stakeholders who might have been left out, especially if disparities persist despite improvement efforts or patients living with the inequities being addressed were not included the first time.
The chart below details RCA activities and estimates the number of meetings for which to plan.
| Key Activities | Resources | Time Estimate: ~14+ Hours |
|---|---|---|
| Identify and invite individuals to your multi-stakeholder team | Diagnose Root Causes with an Equity Lens presentation: Slides 37-42 | 3-5 one-hour meetings |
| Select and invite one or more RCA facilitators Allocate resources and time to plan the Root Cause Analysis (RCA) sessions. Consider the need for multiple sessions and/or meeting locations to accommodate all stakeholders. Secure the meeting spaces and facilitation materials. | Diagnose Root Causes with an Equity Lens presentation Diagnose Root Causes with an Equity Lens presentation Diagnose Root Causes Facilitator Guide | 2-3 one-hour mtgs. |
| Support facilitator(s) RCA session planning | Diagnose Root Causes Facilitator Guide Conducting a Root Cause Analysis with an Equity Lens: Key Considerations | 3-5, 60-90 min. mtgs. |
| Consolidate root causes from the multiple sessions into a fishbone or cause-and-effect diagram | Diagnose Root Causes with an Equity Lens presentation | 3-5 one-hour mtgs. |
| Present final RCA to each stakeholder group for review and approval | 3-5 one-hour mtgs. |
How should I diagnose root causes with an equity lens?
Begin by having your team review the Diagnosing Root Causes With an Equity Lens presentation. Be sure to set aside time for discussing the content. Then have each team member read the Conducting a Root Cause Analysis with an Equity Lens: Key Considerations tool, followed by a group discussion of their perceptions and questions regarding the information within it. Use the Diagnose Root Causes Facilitator Guide to help plan and facilitate root cause analysis sessions with key stakeholders as described in the presentation.
Resources to Diagnose Root Causes with an Equity Lens
Diagnosing Root Causes with an Equity Lens (Presentation)
This presentation covers key concepts like social drivers of health, how structural racism and other forms of oppression underlie health inequities, and practical guidance on using fishbone diagrams and assembling diverse stakeholder teams to diagnose the root causes of health and healthcare inequities. Conducting a thorough root cause analysis provides the information needed to increase the chances of designing a care transformation model that will reduce and eliminate inequities.
Conducting a Root Cause Analysis with an Equity Lens: Key Considerations (Tool)
This primer supports an equity-focused RCA by providing guiding principles, key questions, and considerations to utilize during an RCA session. Considerations are organized across six levels of the health system — policy, community, organization, microsystem, care team, and patients/families.
The primer emphasizes centering the voices of patients living with the inequities and the community-based organizations that serve them, avoiding blame and examining structural factors at each level to surface the true root causes of health inequities.
Facilitator Guide: Diagnose Root Causes
This facilitator guide provides step-by-step instructions for leading teams through a root cause analysis session using an equity lens.
Fishbone Diagram Instructions
Although the steps to complete a fishbone diagram are easy to follow, the process of determining how to fill out the diagram is complex. It requires focused attention as well as input from multiple stakeholders to increase the chances of your team being able to articulate gaps in care that may negatively impact your patient population.
Assessing the Process and Outcomes of Conducting a Root cause Analysis with an Equity Lens
| Topic | Next Steps |
|---|---|
| Planning | Review and discuss the following prompts and use the team’s responses to identify next steps. Have you selected the best “top line” or “head of the fishbone” question of the RCA? * Ensure that the question focuses on structural factors rather than the patients living with the inequities. Who will participate in the Root Cause Analysis (RCA)? * Patients living with the health equity focus * Representatives of community-based organizations that serve people living with the health equity focus * Care team members > Administration > Behavioral Health > Case/Case Management > Community Health Workers/Patient Navigators > Finance/Billing > Government (e.g., state Medicaid) > Health plan / payers > Medical assistants > Nursing > Pharmacy > Primary care > Public health > Quality Improvement / Patient Safety > Reception/Scheduling > Specialty care > Others? Have RCA facilitators been supported in their preparation for the RCA sessions? * If not, what do they need? > What concerns have they expressed? > Can you support them by giving them a chance to practice with the team? > Consider allocating another team member to serve as a notetaker during RCA sessions, which will allow the facilitator to avoid dividing their attention between notetaking and facilitation. |
| Results | Review and discuss the following prompts and use what is uncovered to identify next steps. What were the results of the RCA? * What major categories of analysis were included (e.g., the top-level “Why?” questions)? > Did the RCA miss any potential categories of analysis? – If yes, how might you update the RCA by gathering the missing information? * What surprises emerged? Surprises are a sign that the RCA process served its purpose, illuminating causes previously hidden or considered irrelevant. Were the results and conclusions of the RCA shared with participants for their feedback, giving them a chance to correct misinterpretations or misunderstanding? * If yes, what was their response? > Did they provide feedback to improve or add to your interpretation of the results? * If that feedback was not provided, what steps can you to take to add or improve the interpretation? |
About the Roadmap Goal and Objective Setting Tool
Use the Roadmap Goal and Objective Setting tool to facilitate and document the development, implementation, and evaluation phases of your health equity initiative. It will help your team realize your vision to reduce and eliminate health and healthcare inequities by providing a centralized resource to:
- establish process goals that align with each Roadmap component;
- document task status, identify project champions, and maintain detailed notes;
- monitor progress across multiple Roadmap components simultaneously; and
- promote consistent team communication, accountability, and progress.