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Frequently Asked Questions

#8. What are the comments and responses you've heard in regard to JCAHO's Sentinel Event and Root Cause Analysis Policy?

Just about everything imaginable. Depending upon the knowledge base, the special interests, the financial base, and innumerable other factors different persons, professional groups and commercial enterprises differ strongly in their opinions. It has been referred to as "... a lawsuit kit for attorneys..." (Healthcare Risk Management; July 1998), been hailed as a major advance in health care quality, and everything in between. Remember though that as is true of all JCAHO policies, we are dealing with an evolving entity. A very personal response: I (Kenneth A. Hirsch, MD, PhD) feel that there are certain ways in which the presentation of the JCAHO's goals related to sentinel events and root cause analysis could have been better articulated, better formulated and more palatable. This likely would have improved the general reception given the new requirements. JCAHO didn't ask me, but if they had at that time, I would not have had the benefit of 20/20 hindsight, and it would not surprise me to find that the JCAHO had in fact considered some of "my" ideas and found flaws and adverse impacts of which I remain ignorant. I do not like or approve of a number of the JCAHO's policies, standards, intents, etc. Overall, however, they make sense, and while they become progressively more demanding, the impact is overall quite positive. I feel that will be particularly true of the evolving Sentinel Event Policy, and requirements relating to root cause analysis. I suspect that in retrospect some years hence, we will be asking (1) why it took the JCAHO (rather than the health care industry itself) to get that industry to move in this direction (root cause analysis in response to sentinel events), and (2) why it took the JCAHO so long to do so.

 

  

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About MRMA.  Automate Root Cause Analysis.  Root Cause Analysis Training Comments.  Copyright.  Costeffective Root Cause Analysis.  Credible Root Cause Analysis.  Protection from Discoverability.  Reporting of Sentinel Events to JCAHO.  Root Cause Analysis Cost.  JCAHO Requirement for Root Cause Analysis  JCAHO Sentinel Event Reporting Options.  Proximate cause, root cause versus contributory factor.  Root Cause Analysis on Non-Sentinel Events.  RCA on Sentinel versus Adverse Event.  Reaction to JCAHO Sentinel Event Policy.  Suicide RCA Data.  Root Cause Analysis Policy Implementation.  Root Cause Analysis Standards.  Software facilitation of root cause analysis.  Thorough & Credible Root Cause Analysis.  DoD Sentinel Event Reporting.  Literature Review in Root Cause Analysis.  Root Cause Analysis Training.  FAQ's on Root Cause Analysis.  FOCUS-PDCA.  Guestbook.  Implementing Root Cause Analysis Policy.  MRMA Home.  Inforequest.  Links.  Patient-Doctor Dialog.  Freedom from Restraint.  JCAHO Reporting Options.  Root Cause Analyst.  Thankyou.  Root Cause Analysis Theory.  Root Cause Analysis Training.  Root Cause Analysis Training.  Sample Root Cause Analysis Report.  Sample RCA Contributory Factor Tree Diagram.  Root Cause Analysis Reporting Form. 
About MRMA.  Automate Root Cause Analysis.  Root Cause Analysis Training Comments.  Copyright.  Costeffective Root Cause Analysis.  Credible Root Cause Analysis.  Protection from Discoverability.  Reporting of Sentinel Events to JCAHO.  Root Cause Analysis Cost.  JCAHO Requirement for Root Cause Analysis.  JCAHO Sentinel Event Reporting Options.  Proximate cause, root cause versus contributory factor.  Root Cause Analysis on Non-Sentinel Events.  RCA on Sentinel versus Adverse Event.  Reaction to JCAHO Sentinel Event Policy.  Suicide RCA Data.  Root Cause Analysis Policy Implementation.  Root Cause Analysis Standards.  Software facilitation of root cause analysis.  Thorough & Credible Root Cause Analysis.  DoD Sentinel Event Reporting.  Literature Review in Root Cause Analysis.  Root Cause Analysis Training.  FAQ's on Root Cause Analysis.  FOCUS-PDCA.  Guestbook.  Implementing Root Cause Analysis Policy.  MRMA Home.  Inforequest.  Links.  Patient-Doctor Dialog.  Freedom from Restraint.  JCAHO Reporting Options.  Root Cause Analyst.  Thankyou.  Root Cause Analysis Theory.  Root Cause Analysis Training.  Medical Risk Management Associates.  Sample Root Cause Analysis Report.  Sample RCA Contributory Factor Tree Diagram.  Root Cause Analysis Reporting Form.