| Course | IBC 793 Applied Project |
|---|---|
| Module | Module 8 |
| Paper type | Root cause analysis paper |
| Length | About 433 words, 4 pages |
| Format | APA 7 student paper |
| School | Arizona State University |
| Program | Doctor of Behavioral Health |
| Updated | October 2026 |
Free sample paper for IBC 793 Module 8
Why Adolescents Fall Through the Gap: Current Status and Root Causes
Student Name
Doctor of Behavioral Health, Arizona State University
IBC 793: Applied Project
Instructor Name
Month Day, Year
Why Adolescents Fall Through the Gap: Current Status and Root Causes
Current Status
In the current process, a medical assistant scores the PHQ-9, the pediatric provider reviews it and, if the score is 11 or more, either asks the behavioral health consultant to see the adolescent or gives the family a referral list. A six-month audit (hypothetical) found 74 positive screens at the validated adolescent cut point of 11 (Richardson et al., 2010). Of these, 21 adolescents (28%) were seen by the consultant the same day, seven (9%) completed a later visit within 30 days and 46 (62%) had no documented follow-up. Among the 46, 30 had received only a referral list, and no one had called them afterward.
Root Cause Analysis
A fishbone, or cause-and-effect, diagram organizes possible causes into categories so a team can see the full range of contributing factors (Langley et al., 2009). Staff interviews and the audit identified the following causes.
| Category | Causes identified |
|---|---|
| People | Providers unsure how to introduce the consultant; consultant often in another visit |
| Process | No step for what happens when same-day help is declined; no owner for follow-up |
| Technology | Positive screens not flagged in the record after the visit ends; no registry |
| Environment | Transportation barriers; parents' work schedules; limited Spanish-language follow-up |
Five Whys
The largest cause was the absence of follow-up after a family declined same-day help.
Why was there no follow-up? No one was assigned to contact the family.
Why was no one assigned? The clinic's workflow ends when the visit ends.
Why does the workflow end there? Positive screens are treated as visit tasks, not population tasks.
Why are they treated that way? The record has no registry to show who is still waiting.
Why is there no registry? Behavioral health measures were added to the record without a tracking report.
The root cause is a missing system for tracking positive screens over time, not a lack of effort by staff. Describing it this way also follows quality improvement reporting standards, which ask teams to explain the problem and its context clearly (Ogrinc et al., 2016).
Linking Causes to the Intervention
| Root cause | Intervention component |
|---|---|
| No registry or owner for follow-up | Registry with a care coordinator and seven-day outreach |
| Consultant unavailable | Protected handoff time and a warm handoff script |
| Providers unsure how to introduce care | Script and training |
| Language and access barriers | Bilingual outreach, telehealth and transportation help |
Conclusion
Follow-up fails mainly because the clinic has no system to track adolescents after the visit. The intervention targets that root cause directly, along with the people and access factors that contribute to it.
References
Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.
Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. Journal of Nursing Care Quality, 31(1), 1-8. https://doi.org/10.1097/NCQ.0000000000000153
Richardson, L. P., McCauley, E., Grossman, D. C., McCarty, C. A., Richards, J., Russo, J. E., Rockhill, C., & Katon, W. (2010). Evaluation of the Patient Health Questionnaire-9 item for detecting major depression among adolescents. Pediatrics, 126(6), 1117-1123. https://doi.org/10.1542/peds.2010-0852
IBC 793 Module 8 instructions, in plain terms
Module 8 asks for a 10-point paper on where your problem stands now and why. Describe the present state of your problem in your setting, using the best local data available, and analyze why the problem exists. Tools such as process maps, fishbone diagrams and the five whys help show causes across people, processes, technology and environment. Finish by linking each root cause to a component of your planned intervention, so the reader can see that the project addresses causes rather than symptoms. Label any estimated figures and describe how they were obtained. Interview several staff roles, not just one, so the analysis reflects the whole process. Keep the focus on systems rather than individuals.
How this IBC 793 Module 8 example is built
The paper opens with a step-by-step description of the current process and a baseline broken down by where adolescents are lost. A fishbone table organizes causes into four categories drawn from staff interviews and the audit. A five-whys sequence follows the largest cause to a system-level root cause. The closing table pairs every root cause with a component of the intervention described in Module 7. Margin notes explain why the baseline breakdown matters and why the analysis ends at a system cause. Clinic data are labeled hypothetical, in line with SQUIRE reporting guidance (Ogrinc et al., 2016). The baseline breakdown points straight at the step where most teens are lost.
IBC 793 Module 8 rubric: what earns full marks
Faculty grading the root cause paper look for an accurate description of the current state with data, a structured analysis that considers several categories of causes and a clear link between root causes and the planned intervention. Papers lose points when they describe the problem without data, when causes are listed without analysis, when the analysis blames individuals rather than systems or when the intervention does not address the root causes identified. Using recognized quality improvement tools and explaining how causes were identified strengthens the paper. Analyses that show how causes were gathered, such as staff interviews or chart review, earn more credit than lists based on impression.
IBC 793 Module 8 help from the desk
Map the current process step by step before analyzing causes. Use your baseline data to show where the process breaks down. Gather causes from staff, not just your own observations. Sort causes into categories with a fishbone diagram. Apply the five whys to the largest cause. Stop when you reach a system cause you can change. Link every root cause to part of your intervention. If the causes seem endless, the desk can help you prioritize them. Keep the tone focused on systems, not blame. Draw the process map on paper with a staff member before writing; gaps become obvious quickly. Stop the five whys when you reach something your project can change.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Arizona State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
More IBC 793 and Doctor of Behavioral Health sample papers
- IBC 793 Module 2: SBAR Assignment: Closing the Loop on Positive Adolescent Depression Screens
- IBC 793 Module 3: PICOT Assignment: Building the Applied Project's Clinical Question
- IBC 793 Module 4: PICOT Population Paper: Adolescents With Positive Depression Screens in a Pediatric Clinic
- IBC 793 Module 5: Table Technique: An Evidence Table for the Project's Intervention
- IBC 793 Module 6: Intervention Steps and Timeline: Planning Six Months of Implementation
- IBC 793 Module 7: Evidenced Based Intervention Paper: Warm Handoffs With Registry-Based Follow-Up
- IBC 793 Module 9: PICOT Identified Outcomes Paper: Outcome, Process and Balancing Measures
- IBC 793 Module 10: Measurement Tool Paper: The PHQ-9 for Adolescents and the Project Registry
- IBC 793 Module 11: Proposed Budget: The Costs of Closing the Loop
- IBC 603 Module 5: Case Presentation Paper: Brief Interventions for Depression, Insomnia and Diabetes in Primary Care
IBC 793 Module 8 questions, answered
Where can I find a free IBC 793 Module 8 sample paper?
This page holds the full process breakdown, fishbone table and five whys.
What does the IBC 793 root cause paper include?
The current state of the problem with data and an analysis of its root causes.
What is a fishbone diagram?
A cause-and-effect diagram that groups possible causes into categories.
What are the five whys?
A technique of asking why repeatedly to trace a problem to its root cause.
Should root causes focus on individuals?
No; quality improvement looks for system causes that can be changed.