Open Access Open Access  Restricted Access Subscription or Fee Access

Using root cause analysis (RCA) to facilitate corrective actions, after action reports (AARs), and improvement plans

Ralph Renger, PhD, MEP, Mary Davis, DrPH, Brenda Granillo, MS


Root cause analysis (RCA) is methodology recommended by the Homeland Security Exercise and Evaluation Program (HSEEP) for examining why exercise objectives were not met and providing specific recommendations for corrective action. The consequence of not completing the RCA as required by HSEEP is significant. In the absence of a RCA arriving at the best corrective action is less likely. Despite its importance, there is research evidence from a Centers for Disease Control and Prevention study that the RCA is seldom completed. Several reasons are presented as to why the RCA is not completed including a lack of guidance as to how to conduct a RCA. An example of how to complete a RCA is provided followed by a discussion of the benefits of using the approach over traditional exercise debriefing methods. Reasons why there may be continued resistance to using RCA despite having the necessary facilitation skills and dedicated time are also discussed.


RCA; HSEEP; RCA and exercise evaluation

Full Text:



EPA: How to develop a multi-year training and exercise (T&E) plan: A tool for the water sector. 2011. Available at Accessed January 15, 2012.

HSEEP: Homeland Security exercise and evaluation plan volume I: HSEEP overview and exercise program management. United States Department of Homeland Security, 2007. Available at Accessed February 23, 2012.

HSEEP: Homeland Security exercise and evaluation plan volume III: Exercise Evaluation and Improvement Planning. United States Department of Homeland Security, 2007. Available at Accessed February 23, 2012.

FEMA: Unit 4: Exercise Design Steps. 2012. Available at Accessed July 4, 2012.

Duffy G, Moran J, Riley W: Solve the Real Problem Using Root Cause Analysis. Public Health Foundation White Paper. 2012. Available at Accessed April 27, 2012.

Beitsch L, Moran J, Duffy G: Why Don Berwick was almost right: How public health quality improvement operates in complex systems. J Public Health Manag Pract. 2012; 18(1): 70-73.

Lotstein D, Seid M, Ricci K, et al.: Using quality improvement methods to improve public health emergency preparedness: PREPARE for Pandemic Influenza. Health Affairs. 2008; 27(5): 328-339.

Riley W, Brewer R: Review and analysis of quality improvement techniques in police departments: Application for public health. J Public Health Manag Pract. 2009; 15(2): 139-149.

Seid M, Lotstein D, Williams V, et al. Quality improvement in public health emergency preparedness. Ann Rev Public Health. 2007; 28: 19-31.

Singleton CM, Rose D: Addressing root causes in after-action improvement plans (AAR/IP): Making the most of the AAR/IP to improve preparedness and quality improvement. Paper presented at the Public Health Preparedness Summit, Anaheim, CA, February 22, 2012.

Renger R, Titcomb A: A three-step approach to teaching logic models. Am J Eval. 2002; 23(4): 493-503.

FEMA: IS-130: Exercise Evaluation and Improvement Planning. 2012. Available at Accessed April 28, 2012.

Cole G: Advancing the development and application of theory based evaluation in the practice of public health. Am J Eval. 1999; 20: 453-470.

Doggett AM: Root cause analysis: A framework for tool selection. Am Soc Qual. 2005; 12(4): 34-45.

De Grave WS, Boshuizen HPA, Schmidt HG: Problem-based learning: Cognitive and meta-cognitive processes during problem analysis. Instr Sci. 1996; 24(5): 321-341.

Renger R, Hurley C: From theory to practice: Lessons learned in the application of the ATM approach to developing logic models. Eval Program Plann. 2006; 29(2): 106-119.

Ohno T: Toyota Production System. Portland, OR: Productivity Press, 1988.

Preskill H, Boyle S: A multidisciplinary model of evaluation capacity building. Am J Eval. 2008; 29(4): 443-459.

Mark MM, Henry GT, Julnes G: Evaluation: An Integrated Framework for Understanding, Guiding, and Improving Policies and Programs. San Francisco, CA: Jossey Bass, 2000.

TCL: Target capability list: A companion to the national preparedness guidelines. United States Department of Homeland Security, 2007. Available at Accessed February 23, 2012.

Green LW, Kreuter MW: Health Promotion Planning: An Educational and Ecologicalapproach. 3rd ed. Mountain View: Mayfield, 1999.



  • There are currently no refbacks.

Copyright (c) 2018 Journal of Emergency Management