Conducting Root Cause Analysis

This webinar will review the fundamental principles and techniques of a Root Cause Analysis (RCA) process in support of a culture of safety in hospitals.  We will review the types of hospital related events that threaten patient safety and how to identify and address them for improvement.  The elements of an effective root cause analysis will be discussed as a systems approach to analyzing safety issues and developing targeted actions from their identified root causes. The model for improvement presented allows participants to learn from the underlying causes of errors or problems and to effectively develop solutions to prevent their recurrence while promoting a fair and just culture.


Quality Improvement Contractor under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. 12SOW Compass HQIC Network/Hospital Quality Improvement Contractor – [0395] – 11/16/2023. 

Target Audience

  • Hospital Quality
  • Safety Leads
  • Risk Management
  • Infection Prevention
  • Clinical Managers
  • Staff interested in better understanding and promoting a culture of safety within their organization

Learning Objectives

  • Describe the culture of safety as the foundation for event reporting
  • Recognize a process for addressing adverse events toward identifying areas for improvement
  • Apply the principles of a Root Cause Analysis (RCA) in addressing near misses and adverse events
  • Define and understand the improvement actions supporting a Just Culture
Course summary
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Debbie Logan, RN, MHA, Clinical Improvement Consultant, Mississippi Hospital Association

Deborah G. Logan has over 45 years of experience in nursing with 25 years of healthcare administrative experience.  She has worked in leadership, management, quality and safety, and clinical practice roles. She provides support to hospitals in developing and implementing interventions to improve patient care. Mrs. Logan has a Bachelor of Science in Nursing (BSN) and Master of Healthcare Administration (MHA) from Mississippi College. Her favorite job is being Grandmother to her 5 grandchildren.


Cindy Dishongh, MHS, RHIA, Program Director, Mississippi Hospital Association

Cynthia L. Dishongh has 40 years of experience in healthcare administration as a hospital Chief Executive Officer, Chief Operations Officer, Chief Quality Officer, Patient Safety Officer and Health Information Management Director. In addition, she serves as a doctoral professor of Communications at an academic medical center.  Ms. Dishongh received a Master of Health Science from Mississippi College and a Bachelor of Science in Medical Record Administration from the University of Mississippi Medical Center. 


Steve Lesley, MBA, Director of Data Services, Mississippi Hospital Association

Steve Lesley is Director of Data Services for the MS Hospital Association. He received a B.S. Degree from MS State University in 1981 and his Master of Business Administration from Mississippi State. He has more than 25 years experience in hospital operations improvement with expertise in productivity management, strategic planning and process improvement. Steve has served as State Hospital Association Lead for the Health Research and Educational Trust/MHA Hospital Engagement Network. In addition, he directs the activities associated with the various data programs at MHA such as the State of Mississippi Hospital Discharge Database, CMS program analyses and Economic Impact analyses. Steve directs all activities related to IntelliTrue, the MHA sponsored Heath Information Exchange.


LaNelle Weems, MSN, RN, Mississippi Program Lead, Mississippi Hospital Association

LaNelle Weems has over 40 years of experience in nursing with over 30 years in management and executive nursing administration. Mrs. Weems holds both a BSN and Master of Science in Nursing in Executive Nursing from the University of Mississippi School of Nursing. She serves as the Executive Director of the Mississippi Center for Quality and Workforce (MCQW) within the MHA Health, Research and Educational Foundation. Mrs. Weems’ interests include leadership, workforce development, recruitment and retention, clinical placement administration, patient safety and quality. She currently serves as the Director for Mississippi hospitals participating in the Iowa Healthcare Collaborative (IHC) Compass HQIC, the Director for the Health Resources and Services Administration Rural Communities Opioid Response-Implementation grant and the Delta Systems Implementation Program. She served as the MHA lead for the American Hospital Association’s HRET Hospital Engagement Networks and Hospital Improvement Innovation Network initiatives helping hospitals decrease harms and potential readmissions. She leads multiple projects and initiatives related to quality improvement and workforce development.

No continuing education is provided for this course. The user will receive a certificate of completion upon completing the course.

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