Evaluation of the Root Cause Analysis Process at the VANYHHS

The VA New York Harbor Healthcare System (VANYHHS) charged the Capstone team with the review of Root Cause Analysis (RCA) output measurements, through the Office of Patient Safety. It is the goal of the Office of Patient Safety to effectively use RCA processes as tools to improve clinical operations and quality of care. The team provided the VANYHHS with recommendations on methods, measurement metrics, and potential technological platforms for a database of quality and operational RCA outcome measurements tracking. The recommendations will initially be implemented with the VANYHHS at both the Brooklyn and Manhattan campuses, before being potentially released as recommendations to the national system as a whole.