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#13. What constitutes a "thorough and credible" root cause analysis?

Unfortunately, the JCAHO is still establishing the criteria by which to evaluate the quality of a root cause analysis. This lack of published standards, however, does not mean that there is safety from consequences. Healthcare facilities have already been placed on accreditation watch because of less than adequate root cause analysis.

In evaluating the adequacy of a given root cause analysis, it is advisable to consider not only the final work product, but also the process by which it was developed. Some points to consider:

  1. The JCAHO or other agency examining a root cause analysis will want to be assured of interdisciplinary involvement.
  2. That interdisciplinary involvement must include leadership representation.
  3. There should be a clear effort to include individuals from all involved levels within the organizational hierarchy.
  4. There must be a demonstrated emphasis on root causes rather than proximate causes.
  5. Performance improvement tools should be utilized in the root cause analysis process or methodology.
  6. Use process flowcharts to clarify the way pertinent process are supposed to work, compared with what actually occurred.
  7. The process must demonstrate an effort to identify systems issues rather than simply personnel failures or errors.
  8. The root cause analysis should include a review of pertinent literature.
  9. The root cause analysis must include recommendations for corrective action (improvements) for the root causes identified, an action plan.
  10. Each corrective action should have associated with it a person or persons responsible for the implementation, and a reporting date.
  11. Each action plan item should have a means by which its impact or effectiveness is measured, who is responsible, and when.
  12. The root cause analysis report should be distributed in accordance with your facility's sentinel event policy.
  13. Minutes of appropriate committees, including your executive committee, your medical staff committee, etc., should reflect some cognizance of the root cause analysis and its recommendations.
  14. There must be clear evidence of responsible follow-through with the action plan.

Given the relative novelty of the root cause analysis methodology in its application to the healthcare arena, compliance with any asserted criteria will not guarantee success should a given root cause analysis come to be reviewed. This is an evolving area, and we can anticipate more specific means by which to judge our efforts as the field matures in its use of this set of performance improvement tools.

For an additional and more complete perspective, please see Is your Root Cause "Thorough and Credible?"

 

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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.