October 2023 MITE Hot Topic: RACI Matrix

Author: Hilary Perrey, MHA, LSSBB, CPHQ
MHPI, Improvement Specialist III

Learning Objectives:

  1. Describe what the RACI Matrix is.
  2. Explain how a RACI Matrix is used in clinical performance improvement (PI).
  3. Illustrate an example.

What is a RACI Matrix and how can this be helpful in my clinical PI project? The RACI Matrix is a type of responsibility assignment matrix (RAM) used to identify roles and responsibilities by task including who is Responsible, Accountable, Consulted, and Informed (Forbes Advisor)1.

The RACI Matrix is helpful during the project planning phase where roles and responsibilities need to be defined and shared across all stakeholder groups. By delineating roles and responsibilities upfront, this ensures team members have role clarity, aides in team communication, and supports timely project completion.

To highlight with an example, in FY23 MMC is implementing Intelligent Observation (IO), an electronic hand hygiene monitoring system. The IO implementation is a complex endeavor involving collaboration across a vast number of Clinical, Operational and Support Service stakeholders. The IO rollout involved identifying units and rooms needing communication devices, consulting with unit leadership on device placement, installation, hand hygiene compliance reporting, performance improvement activities and much more. We created a RACI Matrix for both the overall implementation and Quality Improvement support in the two figures below.

Figure 1. MMC Intelligent Observation RACI Matrix for Installation, Badging, and Budgeting for Growth.


Figure 2. MMC Intelligent Observation RACI Matrix for Quality Improvement Support.

What does the RACI Matrix stand for?

Responsible: This role is responsible for task completion. Example: Nursing Patient Care Support and Infection Prevention are responsible for Intelligent Observation compliance reporting since nursing units are the recipients of these reports.

Accountable: This role is accountable for the completion of deliverables and has decision making authority. Example: Quality Improvement is accountable for Intelligent Observation compliance reporting and ongoing performance improvement monitoring.

Consulted: These team members are key stakeholders who should be included in the decision or work activity. Subject matter experts (SMEs) may be consulted in your project since they can provide valuable expertise. Example: Facilities was consulted during a site walk prior to Intelligent Observation installation.

Informed: Informed team members are updated on task completion (Smartsheet)2. For example, in MMC’s Intelligent Observation rollout there were many stakeholders who needed to be informed of project progress, especially unit leadership. By ensuring MMC’s unit leadership is informed of an upcoming Intelligent Observation site visit, this will allow unit managers to identify any equipment needs in advance so their needs can be addressed during the site visit. Keeping team members informed promotes transparency and ensures the team is on the same page.

Where can we find the RACI Matrix Template?

MaineHealth Performance Improvement (MH PI) has a Microsoft Excel RACI template on its SharePoint site at the following link:
RACI Matrix.xlsx


  1. Dana Miranda and Rob Watts. What is a RACI Chart? How This Project Management Tool Can Boost Your Productivity. Forbes Advisor. RACI Chart: Definitions, Uses And Examples For Project Managers – Forbes Advisor
  2. Kate Eby. A Comprehensive Project Management Guide for Everything RACI. Smartsheets. A Project Management Guide for Everything RACI | Smartsheet

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