Alpha Elementary School

Alpha Elementary School is a large elementary school (serving more than 500 students) located in a midsized American city. Alpha Elementary was established more than two decades ago but is now located in a large, modern building with many amenities and flexible learning spaces.1 In recent years, school staff have committed to using approaches such as project-based learning, restorative justice, and targeted community engagement. Most of the students who attend Alpha Elementary live in the neighborhood, leading to the school serving as a central point for social and community events. ost of the students who attend Alpha Elementary face challenges related to inter-generational poverty, educational attainment, and racial discrimination. The vast majority of students at Alpha Elementary are black (as they have been historically), and the school staff generally reflects the student body in terms of race.

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Part 1: Developing a Problem Statement

Alpha Elementary began the root cause analysis process by convening the school leadership team for a half-day session focused on analyzing data, identifying one core problem2 to address, and crafting a problem statement. The school leadership team for Alpha Elementary is quite large, including the principal, assistant principals, and grade-level team leads; these staff were joined by a district comprehensive support and improvement (CSI) specialist and root cause analysis expert facilitators. Most of the members of the school leadership team had been working together for several years and, to outside observers, appeared to have a calm, open, and affable rapport with each other. Because Alpha Elementary had a large school leadership team, facilitators asked these staff to share their school improvement background and experience. This approach allowed the group to better understand each other’s expertise, experience, and perspectives in school improvement, leading to an open and balanced conversation. Likewise, by positioning school improvement as a topic of expertise, facilitators helped staff avoid feeling blamed for poor student performance; instead, staff focused on their expertise and agency in addressing identified problems.

Describing the School “Data Story”

To begin the root cause analysis process, staff analyzed school-performance data using a “Notice and Wonder” protocol. This school-performance data included the school report card, in addition to needs-assessment data and students’ performance on district reading and math assessments (e.g., DIBELS or STAR Math). Staff quickly noticed the main data point that led to Alpha Elementary being identified for CSI: fewer than 15% of students are proficient in reading or math schoolwide. However, many of the other data points staff noticed seemed to add to a more complex and less-clear picture of overall school performance. Using sticky notes, the group compiled the individual data points they noticed and then collaboratively organized the data points by type. The initial “Data Story” for Alpha Elementary is pictured in Table 1.

Table 1. Alpha Elementary “Data Story”

Student Academic Performance Student Population and Engagement Teacher Performance and Engagement Instructional Design and Leadership
  • Fewer than 15% of students are proficient in reading or math.
  • Students are slightly more proficient in reading (just more than 4% proficient) than in mathematics (just under 2% proficient).
  • Students show consistently low proficiency rates after matriculating to middle school (under 15% proficient in reading and mathematics at the middle school level).
  • More students are in the lowest performance category (i.e., Level 1) for mathematics than in reading.
  • Girls tend to perform slightly better than boys in reading.
  • District performance data show a decrease in students who are more than two grade levels below proficiency in both reading and mathematics.
  • District reading data show poor reading fluency performance in lower grades.
  • The student population has increased by more than 30% over the last 3 years.
  • The number of identified homeless students has increased over the last 3 years.
  • Approximately 40% of students are chronically absent, showing a slight but consistent improvement in student attendance over the last 3 years.
  • Teachers have less than 5 years of teaching experience on average.
  • There has been a slight increase in teacher attendance over the last 3 years.
  • There has been a slight decrease in the number of teachers rated ineffective (now 20%).
  • There has been some fluctuation in the number of uncertified teachers in the last 3 years.
  • The school has been recognized for implementing 98% of recommended student-centered instructional approaches.

Facilitation Best Practice

The expert facilitators had the relevant school and district data available and organized in both digital and print format at the beginning of the meeting to minimize the time needed to begin analysis.

Although staff noticed many data points that indicated challenges or problems (e.g., low student performance), they also noticed some positive trends in the data (e.g., increased student and teacher attendance). Rather than simply confirming or clarifying their challenges, the staff at Alpha Elementary expressed a need to spend significant time analyzing data and engaging in discovery around the school’s “Data Story.” Most of these staff had spent the past few years celebrating successful schoolwide improvements in instruction, behavior management, and community engagement; therefore, although low student performance on state and local assessments has been the historic norm for Alpha Elementary, the staff expressed that they were genuinely unsure what was still holding students back from making academic progress.

To better understand Alpha Elementary’s “Data Story,” the staff analyzed the data a second time, this time looking for patterns and progressions across grade levels and subgroups that might help explain how students are responding to instruction over time. From this analysis, some key findings emerged:

  • Student growth on state and local assessments gets progressively worse after third grade. Staff discussed how in third grade, many students face more academic demands but have not yet mastered the necessary foundational skills (e.g., phonemic awareness, multiplication tables).
  • Students across all grades tend to be promoted (i.e., advance to the next grade) even when they are performing far below grade level on state and local assessments.
  • Students who show low or stagnant performance in first or second grade tend to show lower growth rates on state and local assessments over time.
  • Student growth in both reading and math slows substantially for all students in fifth grade; 90% of students are performing below grade level on state and local assessments at the end of fifth grade.

In analyzing these data, staff discussed that although they have made improvements in keeping low-performing students from falling further behind, many other students are not growing or advancing at the rates they should to stay proficient in reading and math for their grade level.

Identifying Data Themes

Once staff were able to describe the Alpha Elementary “Data Story,” staff considered how important and feasible it would be to address each of the data points, which allowed them to narrow down which data points to prioritize in the root cause analysis process. All staff agreed that most students’ low academic performance in reading and math was the primary issue, and that several data points helped explain part of the larger “story” behind these performance gaps. Through discussion, staff identified three themes behind the data to better explain students’ low academic performance:

  • Despite improvements, students with chronically absent students had significantly reduced instructional time and consistently low academic performance.
  • After third grade, student growth is particularly stagnant in both reading and math.
  • Few low-performing students are provided with pull-out intervention supports or retained (i.e., held back).
  • Starting in first grade, the number of students below grade level in reading increases from the beginning of the year to the end of the year.

After spending significant time analyzing and sorting data, staff were able to identify and quickly agree on the themes. However, staff also took time after the data review to candidly raise several potential challenges related to these themes. For instance, staff noted that many teachers at Alpha Elementary do not know how to effectively differentiate or scaffold instruction for students performing below grade level. Likewise, staff discussed how teachers in upper grades can sometimes blame students for not having grade-level skills rather than focusing on how to help close learning gaps. Although these factors were not included in the data that the staff analyzed at the beginning of the day, staff expressed that these pieces of information added to the overall themes and “Data Story” for Alpha Elementary.

Key Challenge Identified

Social promotion of low-performing students contributes to increased performance gaps over time.

In the end, staff came to the conclusion that the challenges related to low academic performance are not simply a grade-specific issue. Rather, staff expressed that the key issue might be social promotion (i.e., allowing students to advance prior to mastering grade-level content). Staff discussed the importance of making sure each student has a solid academic foundation before advancing to the next grade.

Facilitation Best Practice

The leadership team preferred to use a more open-ended process for analyzing their data, which took a significant amount of time but also helped staff feel confident in their decisions and priorities. Other schools may prefer to use a more structured process to sort and analyze data.

With the key challenges (i.e., a dearth of intervention supports coupled with social promotion for low-performing students) identified, staff worked to further refine this challenge and describe it in a problem statement to drive the remainder of the root cause analysis process, which would take place in a separate meeting with a broader group of stakeholders. The expert facilitators stressed that because the problem statement would be the first entry point for the broader group, it was critical that the problem statement be easily understandable at face value and specific (i.e., not too broad to fully analyze during the root cause analysis process). The expert facilitators also clarified that focusing the problem statement now would not limit Alpha Elementary to using CSI funds for one particular student subgroup or specific supports; therefore, there was no risk in being specific in the problem statement (e.g., focusing on one student group). The primary clarification staff needed to make in narrowing the problem statement was whether to focus on reading or math performance. First, some staff noted that improving reading performance may help students better access math content (e.g., word problems, understanding teacher explanations). Next, other staff noted that improving reading skills might help students perform better on standardized tests (especially computer-based tests) in general. Finally, staff noted that while they have had an influx of students in the last 3 years, few of these students have been English learners; therefore, staff expressed confidence in their readiness to improve students’ reading performance.

Crafting the Problem Statement

Alpha Elementary Problem Statement

In Grades 3-5, more than 85% of students are not proficient in reading as measured by state assessments.

In the end, the final problem statement staff crafted for Alpha Elementary read: “In Grades 3-5, more than 85% of students are not proficient in reading as measured by state assessments.” Staff quickly agreed that although the problem statement could include additional detail and data points; likewise, staff realized that much of their discussion about differentiating instruction and social promotion had veered into discussion of root causes rather than focusing on the problem statement alone. Staff agreed that keeping the problem statement succinct would be valuable because it would allow them to hear whether other stakeholders participating in the next meeting would have similar or different perspectives on the factors behind students’ low academic performance. Staff agreed that they would include a summary of their discussion about related data points, differentiating instruction, and social promotion and their analysis of other relevant data points when introducing the problem statement in the subsequent meeting with the broader stakeholder group.

Overarching Facilitation Best Practices

Throughout the process to analyze school data and develop a problem statement, the expert facilitators used several approaches to keep the conversation productive and focused:

  • Focusing on one challenge felt uncomfortable for staff who were hesitant to neglect any aspects of student learning. In response, the expert facilitators emphasized that although it was important for their CSI plan to identify targeted improvements, their day-to-day efforts around improvement were likely to be more holistic in practice. This reassurance set many staff at ease and led to productive discussions.
  • Some staff expressed concerns that by presenting a specific challenge they would be limited in how they could use CSI funds; again, the expert facilitators clarified that having a narrow problem statement would not limit how they would be allowed to use funds to promote improvement.
  • When the discussion veered into speculation, the expert facilitators would ask staff about which data point led to their observation, keeping the conversation grounded in the data at hand.
  • The expert facilitators previewed the different parts of the root cause analysis process so that they could stay grounded in their current step of the root cause analysis process. When leadership team members were identifying data themes and crafting the problem statement, for example, they knew that they would be able to further analyze causes during the upcoming “five whys” activity, which helped deter the group from engaging in analysis or identifying solutions too soon.
  • The expert facilitators used key prompts to help staff reflect on which challenges were most pressing, such as “What keeps you up at night?” or “What would make you worry about your own kids’ education if they attended Alpha Elementary?” Staff expressed that this approach helped them stay focused and contributed to creating a sense of urgency around promoting improvement. The expert facilitators also asked staff to reflect on which data points they might be able to change the most in the next few years, which staff said helped them stay focused on what they could meaningfully change at the school level.

* For more information on CSI funds, please see the U.S. Department of Education’s ESEA Section 1003 webinar presentation.

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Part 2: Identifying Causes

A few days after the meeting to craft the problem statement, the Alpha Elementary leadership team reconvened along with other stakeholders, including a group of teachers in addition to those already on the leadership team and the school counselor. The first meeting with the leadership team staff to develop the problem statement had been just a few hours, but this meeting with the broader stakeholder group was scheduled for most of the day to allow adequate time for discussion and collaborative decision-making.

Orientation and Review

As part of introductions, the expert facilitators asked each person to name one thing that makes Alpha Elementary special or one initiative that has been going particularly well this year. The group shared positive trends based on their perceptions, including the following:

  • A strong sense of identity and community among students and families
  • High engagement from teachers and teacher leaders in decision-making
  • High levels of collaboration and communication across teachers in lower grades
  • Successful implementation of project-based learning and innovative technology labs

After establishing these strengths and successes, the expert facilitators used the discussion on working agreements to frame the transition into focusing on challenges. The expert facilitators reminded the group that the meeting was designed to be a confidential and safe space to share challenges and then asked the group to be honest about what is happening within the school and lean into discomfort where productive. The principal and other members of the leadership team emphasized the importance of honesty as well, encouraging staff to speak their minds freely. Finally, the expert facilitators asked the group to take ownership of their data and challenges so that they could also own their solutions and successes moving forward.

Facilitation Best Practice

During the review of the problem statement, the expert facilitators presented a written version of the problem statement with the “who,” “what,” and “when” of the problem clearly identified, which helped focus discussions on school data.

Next, the principal and other members of the leadership team reviewed the data analysis, themes, and final problem statement with the group. This review prompted a second discussion about which data to prioritize; however, the review of the data helped build buy-in for the problem statement across the entire group. Next, the group reflected on the broader context of their school improvement work, including feeling unprepared for the demands of their jobs, and the perceived disconnect between policy and reality. The group then made explicit connections between the problem statement and their desired outcomes for students at Alpha Elementary, such as “Kids are ready for life beyond Alpha Elementary,” “Kids don’t fall further behind in school,” and “Kids are respected and believed in by others in the future.” These positive statements about desired outcomes helped raise the group’s energy and bring a solutions-oriented attitude to the next activity: identifying causal factors.

Identifying Causal Factors

After identifying the problem statement, the next step of the process is to identify the possible reasons behind the problem (i.e., the causal factors). The group began identifying potential causal factors for the problem statement through silent brainstorming time, writing each one down on a self-adhesive note, and placing it on a large whiteboard. The group generated a large number of potential causal factors3 for the problem statement (see Table 2 below).

Table 2. Alpha Elementary Potential Causal Factors

Student Factors Teacher Factors Other Factors
  • Students have limited soft skills (e.g., perseverance, building relationships, cognitive processing, asking for help when needed).
  • Students have demonstrated exceptionally low proficiency levels in reading (linked to low levels of fluency).
  • Students have low confidence in their own ability to learn and succeed.
  • Teachers have limited knowledge of how to effectively provide social-emotional support.
  • Teachers have limited time to remediate.
  • Teachers have limited knowledge of how to effectively differentiate and scaffold instruction for low-performing students.
  • Teachers have implicit biases and low expectations of students.
  • Teachers have discomfort with analyzing and using data to inform instruction.
  • There are inadequate early intervention resources in lower grades.
  • Families have limited supports for student learning at home.

Next, the expert facilitators asked volunteers to come up to the wall and organize the potential causal factors into six “starter” categories: (1) instruction, (2) curriculum, (3) social-emotional learning, (4) culture and climate, (5) systems, and (6) teacher efficacy. After about half the group organized the sticky notes into the six categories, the whole group engaged in a “notice and wonder” reflection about the potential causal factors. In this exercise, the group noted the following:

  • Most of the potential causal factors identified were in the “systems” and “teacher efficacy” categories. Some participants suggested that many of the challenges center on adults rather than students, whereas staff at Alpha Elementary tend to focus on students’ challenges or issues in their daily discussions.
  • Although many staff members may perceive curriculum to be a major issue, this exercise showed that there are other more pressing issues affecting the problem statement.
  • Although there were some potential causal factors related to implicit bias and social-emotional learning, these factors may have broader influence and play a more significant role than assumed.

Facilitation Best Practice

The expert facilitators frequently re-oriented the conversation by asking the group to reflect on which issues might have the most impact on the problem statement, which helped the process move relatively quickly.

With “systems” and “teacher efficacy” identified as the top two categories of potential causal factors, the group discussed which factors in each of these categories were most significant and within their locus of control at the school level. This discussion led to a key clarification between systematic challenges (e.g., poor teacher preparation) and challenges with the school systems (e.g., scheduling), which resulted in few causal factors in the “systems” category that school staff could directly address. With this clarification, the group agreed that causal factors related to teacher efficacy were the most pressing and relevant for them to address.

The group began analyzing the potential causal factors starting with the “teacher efficacy” category, voting on the factors they perceived to be the most important or significant.

  • For “teacher efficacy,” the group identified low levels of teacher ownership (i.e., a lack of confidence and therefore lack of effort to address challenges) as the most important causal factor. However, the group expressed hesitance to consider instructional practices within the “teacher efficacy” category, demonstrating some reluctance to take ownership for teacher knowledge and skills. In addition to low levels of teacher ownership over challenges, which the group described as voluntary, the group also identified teachers’ low levels of content knowledge and understanding of standards as an important causal factor, though one that was perceived as involuntary.
  • For “curriculum” and “instruction,” there was some disagreement over whether teachers have control over instruction. Although the principal and a few other school leaders expressed a strong belief that they have control over curriculum implementation, some teachers expressed that they felt restricted by the curriculum. In the end, the group agreed to combine these categories into one given the difficulty in differentiating between these types of factors.
  • For “social-emotional learning” and “culture and climate,” the group focused on how high rates of student absenteeism and low family engagement (e.g., low participation in parent-teacher conferences) make it difficult to provide consistent social-emotional learning supports. The group decided to combine these categories into one.
  • For “systems,” the group identified low levels of teacher engagement in professional learning and mixed implementation of recommended instructional strategies.

Having now modified the causal factor categories to (1) teacher efficacy, (2) teacher knowledge and skills, (3) curriculum and instruction, (4) social-emotional learning, and (5) systems, the group broke into four smaller groups to refine their causal factor statements for each of these categories. This process took more than 30 minutes with support from expert facilitators, including using examples and peer feedback to refine and clarify the causal factor statements to be accurate and specific. The expert facilitators prompted the group to focus on how the causal factor statements described the conditions that led to the challenge described in the problem statement. The final causal factor statements are shown in Table 3.

Table 3. Causal Factor Statements

Teacher Efficacy Teacher Knowledge and Skills Curriculum and Instruction Social-emotional Learning Systems
Teachers do not feel capable of addressing students’ learning needs. Teachers do not know how to differentiate instruction to support low-performing students while maintaining grade-level instruction. Students rarely receive differentiated instruction. Students do not have the skills or confidence to meet the expectations of state assessments. Systems currently in place to build teacher capacity have not made a significant impact on teacher practice or student outcomes.

Once these causal factor statements were drafted and agreed upon, the group transcribed them in the outer boxes in a fishbone diagram in preparation for the next activity: analyzing underlying and root causes.

Analyzing Underlying and Root Causes

Facilitation Best Practice

The expert facilitators reminded the group at the beginning of the “five whys” protocol that they could not unilaterally solve systemic racism or trauma. To help curtail discussions that did not help the group focus on issues they could solve, the expert facilitators periodically noted when the discussion moved too close to “systemic racism” and asked the group to move on.

Prior to analyzing the underlying and root causes for each causal factor statement, one of the leadership team members brought in a fourth-grade student to participate in the process as well. The leadership team clarified that although they did not feel it was appropriate for an elementary student to participate in an all-day process, they wanted to meaningfully include a student perspective in the discussion of challenges and potential solutions. The group then revisited their norms around focusing on what they have the capacity to change; the expert facilitators committed to noting when the group might move to challenges that they considered to be outside of their control4 and refocus the discussion. Likewise, the group committed to focusing on possible causes rather than spending time debating whether a cause could be proven true (or not).

The group collaboratively engaged in a “five whys” protocol for each of the causal factor statements. While the discussions during the “five whys” protocol were often not linear, these discussions were eventually successful in uncovering the underlying factors leading to the previously identified challenges. Key insights from the discussion included the following:

  • The group noticed that teacher efficacy, teacher knowledge and skills, curriculum and instruction, and systems were all more similar than the group initially believed.
  • The group recognized that although teachers need more knowledge about how to help low-performing students close learning gaps, the primary challenge is teachers’ willingness to implement new strategies and instructional supports. The importance of teacher efficacy and their belief in students’ ability to succeed are both supported by research. This point was further emphasized by contributions from the fourth-grade student to the discussions: the student shared the perspective that although their teachers show that they believe in students by asking them to behave and work hard, they do not offer enough support or help when students need it.
  • The group noted that although they cannot change state or district policy to make teachers more accountable for student outcomes or their engagement in professional development (PD), they can help teachers at Alpha Elementary become more engaged through inter-personal efforts.

The final fishbone diagram is shown in Figure 1.

Endpoint is Low Student Performance. Contributing factors are Teacher Efficacy; Teacher Knowledge and Skills; Curriculum and Instruction; Social-Emotional Learning; and, Systems. Each of these have further contributing factors.

Root Cause Identified

Teachers don’t believe they can help students close their learning gaps (and may not know how).

After developing an initial fishbone diagram, the group voted together as to whether they believed each of these categories showed contributing causes (i.e., causes that may or may not need to be addressed) or root causes (i.e., causes that must be considered to address the problem). Through voting activities and discussion, the entire group agreed that limited teacher efficacy is the main root cause of the problem statement, whereas the other causal factors include contributing causes (rather than root causes). With the root cause of the problem statement successfully identified, the group moved on to the final part of the root cause analysis process: identifying strategies


icon of a lightbulb as puzzle pieces

Part 3: Identifying Solutions

In pivoting to strategy selection, the group expressed a feeling of accomplishment for working through tough questions and data together for several hours. To refresh and refocus the group’s thinking, the expert facilitators asked the group to rehash the strengths of Alpha Elementary that they brainstormed earlier in the day. After approximately 10 minutes of discussion, the group pivoted to thinking about what potential strategies they might use to improve teacher efficacy, considering what might be most successful given their strengths as a school. Some participants expressed confusion about what kinds of strategies they were expected to implement – for instance, one teacher participant asked whether a strategy could be buying coffee for teachers or whether it had to be some kind of professional learning. The expert facilitators clarified that they should start by brainstorming all strategies, after which they would refine and pick those that were evidence-based and most likely to have a significant impact. Through discussion, the group developed a few different strategies to implement now; however, the group also committed to exploring additional strategies through the lens of their reflections and priorities determined through the root cause analysis process. The final list of strategies selected included the following:

  • Include teachers in shared decision-making and leadership. Although this approach was previously recognized as a strength of the school, the principal and other members of the leadership team recognized that by including more teachers in leadership conversations they could build better buy-in and participation in making changes.
  • Provide teachers with social-emotional supports. The group emphasized their belief that for teachers to improve their self-efficacy, they would need to develop a growth mindset; likewise, teachers would need to develop better relationships and rapport with each other so they can receive positive affirmation and support.
  • Recognize teacher growth. The leadership team committed to recognizing small but positive changes in teacher growth and small wins for the school overall, letting teachers know they are valued and their efforts are important to the school community.
  • Engage in book studies as part of professional development. Although school leaders cannot control teachers’ personal professional development selections, the group expressed a desire to set up school-based book studies that teachers could use for professional development hours. These book studies could address specific strategies for helping low-performing students close gaps and provide a “support group” for teachers trying to implement these strategies over time. A teacher participant also suggested sharing printed articles with staff to read and share reflections about in staff meetings (for those unable or unwilling to participate in book study groups).
  • Improve communications and connections across lower and upper grades. One teacher participant noted that in the discussion of causal factors, they had discussed how teachers in lower grades tend to believe students have time to “catch up” in upper grades, whereas teachers in upper grades do not believe they can meet students’ learning needs. To address these beliefs, the group suggested creating opportunities for intentional cross-grade communication about student learning trends and strategies. Because Alpha Elementary already uses a system for cross-grade communication across the lower grades, the group planned to replicate this system for communicating with upper grades. The group also noted that more cross-grade communication might have an added benefit of improving communication about individual students’ and families’ needs.

In closing, the group reflected on the importance of bringing a growth mindset to the work themselves by continuing to identify and try potential strategies in spite of setbacks or challenges along the way.

To learn more about how the root cause analysis process fits into the broader school improvement planning process, please see the Using Evidence to Strengthen Educational Investments non-regulatory guidance from the U.S. Department of Education.


1Flexible learning spaces allow teachers and students to move and change learning settings as needed for individual, small group, or whole group instruction. For more information, please see the Flexible Learning Environments(link is external) summary by the California Department of Education.

2 The core problem identified in Alpha Elementary School’s root cause analysis process was required to be related to school improvement.

3 While all causal factors are grounded in the needs assessment data, these factors are based in the perceptions of root cause analysis participants.

4 Challenges referenced by the group included systemic racism, poverty, and economic opportunities in the city.