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
Page 1 of 23
,*Disclaimer: The framework found on Joint Commission Connect™ will show the most current iteration of
this form.
Page 2 of 23
, EVENT DESCRIPTION
When did the event occur?
Date: Day of the week: Time:
Detailed Event Description Including Timeline:
Diagnosis:
Medications:
Autopsy Results:
Past Medical/Psychiatric History:
Page 3 of 23
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
Page 1 of 23
,*Disclaimer: The framework found on Joint Commission Connect™ will show the most current iteration of
this form.
Page 2 of 23
, EVENT DESCRIPTION
When did the event occur?
Date: Day of the week: Time:
Detailed Event Description Including Timeline:
Diagnosis:
Medications:
Autopsy Results:
Past Medical/Psychiatric History:
Page 3 of 23
