Apr 25, 2022

Getting to the Root Cause to Support Continuous Improvement

Chris Brandt
Juan D'Brot
Lori Vandeborne
Ann Weber
3d rendering of question mark on multiple multi-color speech bubbles

The Region 5 Comprehensive Center (R5CC) along with state leaders in Kentucky, Tennessee, Virginia and West Virginia has been working to develop and implement Networked Improvement Communities (NIC) to inform improvement initiatives with an organized approach. This blog provides an overview of Step 4 in the 8-step NIC process, conducting a root cause analysis. You may also access ready-made facilitator resources on the NIC website.

A root cause analysis allows a NIC team to fully explore the underlying reasons contributing to a problem before the NIC moves ahead to identifying solutions. A root cause analysis can:

  • Introduce new and multiple perspectives on the problem
  • Prompt discussion about why unsatisfactory outcomes occur
  • Break large problems into smaller, actionable pieces
  • Improve the development of targeted and measurable outcomes

The process of conducting a root cause analysis encourages a team to engage in an open and honest conversation, and to set aside preconceived biases about why a problem is occurring. By breaking down the initial causes into finer-grained problems, a team can pinpoint some of the reasons why things happen the way they do, and potentially find more effective solutions that address the root cause.

After identifying an initial high-level problem, one technique is to ask a series of “why?” questions to consider subcauses that influence the initial problem. Asking, “Why are we getting the results we observe?” repeatedly, typically four or five times in a row, can help to generate the root cause.

For example, one state identified the lack of universal technology access for all students as an initial problem. Asking a series of repeated “why?” questions revealed the following root causes:

  1. Districts did not budget for technology
  2. Universal technology was not a necessity until 2020
  3. Face-to-face instruction enabled districts to overlook need.
  4. Teachers prefer using traditional practices; technology literacy varies
  5. Teachers perceive technology as unreliable, more trouble than it is worth.

The root cause analysis helped to identify a more concrete and narrow cause (“teachers perceive technology as unreliable”) than the original problem statement (“technology is not universally available”). As a result, developing an approach to the problem of universal access can now reflect a deeper understanding of underlying causes.

A fishbone diagram is one useful way to organize and connect initial causes to narrower related causes that lead to a root cause. This tool can also be used to communicate with other participants in a NIC.

Template for identifying concrete and narrow causes, resulting in a clear problem statement

An in-depth root cause analysis may take time to fully develop, and as new subproblems emerge, they can be added to the fishbone diagram and addressed separately. After completing the initial root cause analysis, the fishbone diagram can be presented for discussion, then revised and updated based on feedback from stakeholders to capture a comprehensive list of root causes.

For a deeper dive into the content around how to identify root causes, visit the R5CC Networked Improvement Community facilitator resources for Conducting a Root Cause Analysis.

For more information and support, contact the Region 5 Comprehensive Center.


Bryk, A.S., Gomez, L.M., Grunow, A, and LeMahieu, P.G. (2015). Learning to improve. Cambridge: Harvard Education Press.