Federal regulations require the facility Infection Preventionist (IP) to be a participant on the facility’s Quality Assessment and Assurance (QAA) committee and report on the Infection Prevention and Control Program (IPCP) and on incidents (e.g., healthcare-associated infections (HAIs)) identified under the program on a regular basis. Reporting may include, but is not limited to, facility process and outcome surveillance, outbreaks (ongoing and any since the last meeting) and control measures, occupational health communicable disease illnesses (e.g., TB, influenza) and the Antibiotic Stewardship Program (ASP) related to antibiotic use and resistance data.

In order for the QAA committee to put effective corrective actions in place in response to infection events, it is important for the IP to perform root cause analysis (RCA) on infections occurring in the facility, to understand why the infections occurred. RCA is a term used to describe a systematic process for identifying contributing causal factors that underlie variations in performance. The purpose of conducting a RCA is to find out what happened, why it happened, & what changes need to be made.

The steps for conducting a RCA include the following:

      1. Identify the event to be investigated and gather preliminary information
      2. Select a team facilitator and team members to be involved in the RCA process
      3. Describe what happened
      4. Identify contributing factors
      5. Identify the root causes
      6. Design and implement changes to eliminate the root cause
      7. Measure the success of change

Performing a comprehensive review of all aspects of each infectious event will assist in limiting infectious spread within your facility, which promotes resident safety and quality of life. Your detective work is a critical part of the IPCP processes in your facility and should be done thoroughly with each infectious event.

Want to learn more on how to conduct RCA of infections occurring in your facility? Plan to join us on August 16th as we discuss the IP’s role in QAPI and how to use the RCA process.


Cowritten by Judy Caffrey, RN and Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC

Learn more about the rest of the Proactive team.