Is your Root Cause Analysis "Thorough and Credible?"
Reprinted with permission of Opus Communications from Briefings on Adverse and Sentinel Events, July, 1999.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that your Root Cause Analysis (RCAs) be thorough and credible.
"Thorough" and "credible" are not particularly difficult concepts until it's time to apply them while conducting an RCA. Or when the JCAHO comes calling during survey to make sure your systems are up to snuff, including your RCAs.
However, you don't have to be completely stranded when it comes to determining whether an RCA is thorough and credible. The JCAHO considers several criteria for a thorough and credible RCA.
These criteria address five key issues, according to Rick Croteau, MD, executive director for strategic initiatives at the JCAHO. As outlined in First Do No Harm: A Practical Guide to Medication Safety and JCAHO Compliance, published by Opus Communications, the key issues are the following:
Do the people who completed the RCA have first-hand knowledge of the incident and/or the processes involved in that incident?
Does an organization's leadership support the investigation's findings?
Do the findings identify system-related defects rather than blaming human error or individuals?
Is the analysis consistent (i.e., do some parts of the report contradict or raise questions about others)?
Does the investigation include a review of relevant literature--to ensure that an organization draws on lessons learned elsewhere?
The JCAHO book, The Joint Commission on Accreditation of Healthcare Organizations, Sentinel Events: Evaluating Cause and Planning Improvement, lists even more specific expectations and criteria, which are paraphrased below:
A Thorough Root Cause Analysis:
identifies proximate causes
(late-stage variations and related processes) and systems
reviews related systems and
processes
identifies
underlying/system-related cause(s) of the proximate cause(s) and
explains their potential role in the event
continuously focuses on
opportunities to improve systems, and if none are apparent, can explain
why
outlines a plan to address
opportunities to improve or explains why the organization isn't
addressing those opportunities
explains when improvement plans are justified
- who will carry out the plan;
- when that person(s) will carry out the plan; and
- the methods for measuring results
A Credible Root Cause Analysis:
involves people closely associated
with all aspects of the systems and processes under review
receives support, authorization,
and encouragement from senior leadership
presents findings that are
consistent and whose conclusions all RCA team members endorse
considers all relevant literature
is distributed to anyone who can
benefit from the findings
Don't let language be misleading
Steven W. Bryant, practice director
for accreditation at The Greeley Company in Marblehead, MA, says that the
aforementioned criteria are, for the most part, workable. However, he does
warn about language that the JCAHO sometimes uses. For example,
"proximate" can have several meanings, including "next," "close," "near,"
"immediate," and "present," he says. In the context of "proximate" causes,
Bryant says it's better to think in terms of "immediate." Those are the
causes that immediately come to your attention, he notes.
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