Prioritize Root Causes

By the end of the root cause analysis (RCA), multiple causes of the targeted health inequity should be evident. The next step is selecting which root causes to prioritize for intervention via transformation of the healthcare system. This isn’t always the easiest decision. Prioritizing the most specific root causes can help because they are often the key drivers of the inequities. In a fishbone diagram, these are the smallest branches (“bones”) of the fish diagram.  However, there are other factors to consider, such as feasibility.

One way to consider multiple factors when prioritizing root causes of a health inequity for intervention is to utilize a priority matrix. A priority matrix is a two-by-two square that helps you ask two major questions about each of the identified root causes:

• How feasible is it to tackle the cause?
• How important is it to tackle the cause?

If you recruited a well-informed and diverse team to conduct the root cause analysis, the same group of people will be ideally suited to answer these questions and arrive at a consensus. 

2×2: A priority matrix helps identify which root causes to prioritize

Assessing Importance and Feasibility

Quantitative data (e.g., community needs assessment) and qualitative data (e.g., patient and community focus groups) can help you assess the feasibility and importance of root causes. Common considerations that teams might take into account include:

• Impact
  • How much of the priority population is affected by the root cause?
  • How might health and quality of life be improved if the root cause is addressed?
• Urgency
  • Is prompt/immediate action required?
• Cost
  • How much funding is needed to address the root cause and over what period of time?
  • Does the issue currently cost the organization a lot of money or staff time?
• Effort
  • How labor and time-intensive will it be to address the cause?
  • Is there sufficient team member capacity to support the necessary care transformations? If not, how much more is needed?
  • Are there significant information technology needs?
• Readiness and political will
  • Is there momentum and willingness to address this cause? If not, what needs to change?
  • What are the perspectives of different stakeholder groups regarding readiness (e.g., patients, community, health care provider organization team members, leadership of partner organizations)?
• Existing resources and infrastructure
  • What resources are already in place that can help address the root cause?
• Moral and ethical considerations
  • What are the moral and ethical implications of not addressing the root cause? How do they inform the assessment of importance?

Some teams may wish to utilize a more nuanced three-by-three priority matrix with three importance categories on one side (Most Important, Moderately Important, Least Important) and three feasibility categories on the other (Most Feasible, Moderately Feasible, Least Feasible).

3×3: A priority matrix helps identify which root causes to prioritize

Selecting Root Causes

A completed priority matrix will help the team create an equity-forward care transformation and a payment transformation to support it.  Consider the following when selecting root causes for intervention:

• Start by reviewing the root causes that are very important and very feasible.  These may be the ideal causes that your equity-focused care transformation should address.
• There is nothing wrong with initially focusing on an easier root cause. A relatively quick win can help build momentum, garner leadership support, and motivate team members to address additional root causes.
• It can also make sense to prioritize a very important but less feasible root cause.
• Consider focusing on multiple root causes. Which ones can be addressed in the short-term, the mid-term, and the long-term? Sometimes it may make sense to design and implement a multi-faceted care transformation that has short-term (6 months – 18 months); mid-term (18 months – 3 years); and long-term (3+ years) phases and goals.

Solution matrix: A priority matrix will help us choose the most important and feasible root causes to address