FRAMEWORK FOR ROOT CAUSE ANALYSIS AND CORRECTIVE ACTIONS*
The Joint Commission’s Framework for Root Cause Analysis and Action Plan provides an example of a comprehensive systematic analysis. The framework and its 24 analysis questions are intended to provide a template for analyzing an event and an aid in organizing the steps and information in a root cause analysis.
An organization can use this template to conduct a root cause analysis or even as a worksheet in preparation of submitting an analysis through the online form on its Joint Commission Connect™ extranet site. Fully consider all possibilities and questions in seeking “root cause(s)” and opportunities for corrective actions. Be sure to enter a response in the “Analysis Findings” column for each item. Unexpected findings may emerge during the course of the analysis, or there may be some questions that do not apply in every situation. For each finding continue to ask “Why?” and drill down further to uncover why parts of the process occurred or didn’t occur when they should have. Significant findings that are not identified as root causes themselves have “roots.” “Corrective Actions” should be developed for every identified root cause.
While the online form provides drop-down menus for many of the form’s cells, the options for these columns are provided here in the following tables:
The following are in the Root Cause Analysis section:
Root Cause Types: Table A-1 (column 1)
Causal Factors/Root Cause Details: Table A-1 (column 2)
In the Corrective Actions section, the following are added: Action Strength: Table A-2
Measure of Success: Table A-3 Sample Size: Table A-4
*Disclaimer: The framework found on Joint Commission Connect™ will show the most current iteration of this form.
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