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#10. Once a root cause analysis is done, who should be responsible for making certain that any recommended changes are implemented?

You can bet that the JCAHO will ask you this question on your next survey! Who or what office or department will best accommodate that responsibility will differ among different facilities. It may be your continuous improvement department, the risk management office, etc. In general, it is our feeling that this is an appropriate activity for the first of these, e.g., your continuous improvement department or equivalent. Critical points, however, include that:

Define the root cause analysis process

There is a formal process for this (we recommend the use of flowcharts in helping to clarify the process in your procedure manuals),

Assign responsibility for the root cause analysis process

Responsibility is given in that process to a specific, identified entity within your organization,

Document the follow-through on root cause analysis recommendations

It can be documented that those recommendations are acted upon,

Evaluate the impact of root cause analysis recommendations

 The effectiveness of the recommendations is assessed in a formal and data-driven manner.

 

  

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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.