Open in browser
Navigate to gembasuite.org/rca in Chrome (Android) or Safari (iOS/iPadOS). Works in any modern browser on desktop too.
Add to home screen
Android: Three-dot menu → Add to Home screen. iPhone/iPad: Share button (□↑) → Add to Home Screen. Gemba-RCA will then load offline from cache.
Fill in the project fields
| Field | Notes |
|---|---|
| Session name | Identifies this RCA in your project list. Include work area and problem, e.g. Delayed TAT — Haematology |
| Work area | Department or ward where the problem is occurring |
| Author / Org | Appears on exports and AI coaching prompts |
| Date | Defaults to today — adjust if needed |
Choose problem statement entry route
Standalone — type the problem statement directly in the modal. Use a specific, quantified statement: what, where, how often, against what standard.
Import from A3 — if you have an active Gemba-A3 project, tap Select Gemba-A3 JSON file and choose your A3 export. The Section 1 problem statement is pre-populated automatically.
Export often
localStorage can be cleared by the OS without warning. Tap Download JSON in the Pareto & Export tab after every session. If you have not exported, you have not saved.
Six default categories
The Fishbone has six bones: People, Equipment, Method (top) and Materials, Measurement, Environment (bottom). These map to the 6M framework. Rename any category by tapping the pencil icon on its card — the SVG diagram updates automatically.
Add causes to each category
Tap + Add cause in any category card. Enter a brief, specific description. Causes appear in the card list and on the corresponding bone in the SVG diagram. Work through all six categories before moving to selection — the most significant cause may not be in the most obvious category.
Select up to 3 causes for investigation
Tap any cause text in a category card to select it. Selected causes highlight in the card. The toolbar shows the count: 0 of 3 selected. Select the causes your team judges most significant — you will investigate each with a 5 Whys chain. You need at least one selection to use the 5 Whys tab.
Tip
Measurement and Environment are the most commonly under-populated categories in healthcare RCAs. Spend deliberate time on both before selecting causes to investigate.
Navigate between chains
Each selected cause appears as a tab at the top of the panel. Tap a tab to view and edit that chain. Chains are independent — work through each separately.
Add Why steps
Tap + Add Why step to add the next level. Each step has two fields:
| Why answer | Why does the previous level occur? Concise and specific. "We don't know" is valid — it means a gemba visit is needed. |
| Evidence | What data, observation, or document supports this? Unevidenced steps are hypotheses, not findings. Leave no evidence fields blank. |
Know when to stop
Stop when removing the cause would eliminate the problem. Continue if the problem would still occur without it. Typical chains are 3–6 steps. Stopping at "staff didn't follow the procedure" is almost always too soon — ask why they didn't follow it.
Validate each root cause
At the bottom of each chain is the root cause validation panel. Answer the question: "If we address or remove this cause, does the problem disappear?"
| ✓ Yes — Validated | Chain is marked Root Cause Validated (green). This chain is included in the A3 export. |
| ✗ No — revisit | Chain is marked Not Validated (red). Either go deeper in the Why chain or reconsider the selected cause. |
Check the logic — Therefore Validation
Tap the ▶ Check logic button (top-right of the chain panel) to switch to Therefore view. This reads the chain bottom-up — from root cause back to the original cause — letting you verify the logical connection at each step.
| 👍 Holds | The logical connection between this pair is sound. |
| 👎 Gap | The step does not follow clearly — an amber ⚠ warning appears in edit view so you can revisit that level. |
Tap ◀ Edit view to return to editing. This check complements the elimination test — together they confirm both that the deepest cause is genuine and that the path from root cause to problem is logically coherent.
Build the Pareto chart
Tap + Add cause in the Pareto section. Enter each candidate cause and the number of incidents attributable to it. The SVG bar chart orders causes by frequency automatically. The causes on the left — the steep bars — are your vital few. Address these first.
Data should come from actual observation: incident logs, tally data, LIMS queries, or audit data. Estimated figures are acceptable when hard data is unavailable — note the basis.
Export your findings
| Category | What it covers | Healthcare examples |
|---|---|---|
| 👥 People | Skills, training, staffing, communication, task allocation | Phlebotomist training on culture collection; handover communication gaps; shift staffing ratios |
| 🔧 Equipment | Devices, analysers, IT systems, maintenance, calibration | Analyser downtime; EPR system latency; barcode scanner failure; centrifuge imbalance |
| 📋 Method | SOPs, clinical pathways, protocols, work sequence, handoffs | Sample labelling SOP not followed; no defined escalation pathway; ambiguous referral criteria |
| 📦 Materials | Samples, reagents, consumables, forms, labels | Haemolysed samples; reagent shortage; inadequate sample volume; illegible paper requests |
| 📊 Measurement | Data quality, KPIs, feedback loops, reporting frequency | TAT measured from receipt not collection; no daily feedback to ward; SLA not visible to lab |
| 🏥 Environment | Physical space, layout, noise, adjacency, workspace design | Sample receipt area shared with high-traffic corridor; poor storage organisation causing specimen misplacement |
| Tool | What it provides to RCA | What RCA provides back |
|---|---|---|
| Gemba-VSM | Process map, lead time data, location of defects / delays — sharpens the problem statement | — |
| Gemba-A3 | A3 JSON → problem statement import (Section 1) | RCA JSON → root causes + Fishbone SVG import (Section 5) |
| Gemba-SPC | Special cause signals → problem statements for new RCA cycles | — |
Remember
All data transfers between Gemba Suite tools are manual JSON export/import — user-controlled. No data moves automatically. Export JSON from RCA → open Gemba-A3 → import the file.