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 strategic 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:

1. Do the people who completed the RCA have first-hand knowledge of the incident and/or the processes involved in that incident?
2. Does an organization's leadership support the investigation's findings?
3. Do the findings identify system-related defects rather than blaming human error or individuals?
4. Is the analysis consistent (i.e., do some parts of the report contradict or raise questions about others)?
5. 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:

• 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 —
  1. who will carry out the plan;
  2. when that person(s) will carry out the plan; and
  3. the methods for measuring results

• 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.