What does The Joint Commission expect after a sentinel event?

Under its Sentinel Event Policy, accredited organizations complete a comprehensive systematic analysis, most often an RCA, and a corrective action plan within 45 business days of the event or of becoming aware of it, then implement the plan and monitor whether it works. ImprovementFlow keeps the analysis, the actions and the monitoring on one record.

What is RCA², and can we follow it?

RCA² (root cause analysis and action) is the National Patient Safety Foundation's 2015 guidance for making RCAs lead to effective actions: risk-based prioritization, a small team, stronger actions with a measure for each, and leadership review. Your RCA template can follow its steps and prompts.

How do you keep action plans from being all training and policy?

Build the action hierarchy into your RCA template's prompts, so teams look for a stronger or intermediate action for each cause, and give every action an owner and a measure. Reviewing the plan by action strength makes a plan full of weaker actions visible before it's approved.

Do we have to run a full RCA on every event?

No. Many organizations reserve a full RCA for sentinel and serious events and use lighter reviews for others. The severity and tags on each event help you decide, and any event can still become a linked project when the review shows it needs one.

Can we tell the reporter what the RCA changed?

Yes. Reviewers can send feedback to the person who submitted the event, so a named reporter hears what was done. People who stay anonymous see what happens next when they submit.

HIPAA compliance, a BAA and SSO are included in every package.

ImprovementFlow · Improvement Methods

Root cause analyses that end in actions that work, not "re-education for staff"

Start the analysis straight from the safety event, work the causes with the team, and turn each one into a corrective action with an owner, a due date and a measure. ImprovementFlow keeps the RCA linked to the event that started it, shows leaders which actions are done, and closes the loop with the person who reported it.

Request a Demo Follow one RCA to its actions

In an empty hospital patient room, a nurse shows how the bed-exit alarm on the side rail is set while a biomedical engineer checks its cable, a physician listens, and a patient safety officer with a clipboard stands at a whiteboard with a timeline of sticky notes and a branching cause diagram

Sound familiar?

What we hear from patient safety and risk leaders using standard approaches

Common frustrations with the usual tools and workarounds — the gaps ImprovementFlow is built to close.

Our action plans keep ending in "re-educate staff" and "reinforce the policy."

Weak actions are the easiest to write and the least likely to stop the next event.

We finish the RCA on time, then nobody checks whether the actions actually happened.

The analysis gets the deadline. The follow-through gets a spreadsheet nobody owns.

The same kind of event came back a year later, and the new team started from scratch.

When RCAs live in separate documents, nobody sees that three reviews pointed to the same cause.

How it works

From the safety event to an action that holds

Keep your RCA team, your review process and the RCA² approach. ImprovementFlow gives every cause and every action a place, an owner and a measure.

1
Start from the event
Reviewers create a linked project directly from the safety event, using the ready-made RCA template, so the analysis keeps the original report, its severity and the people involved in its review.
2
Work the causes as a team
The team describes what happened, lists the gaps and the root cause behind each one, and uses tools such as 5 Whys and fishbone diagrams to look past the individual to the system.
3
Choose stronger actions
Each cause gets at least one countermeasure. Your RCA template can prompt teams toward actions that change the design of the work, such as forcing functions and standardized equipment, rather than more training and reminders.
4
Track every action to done
Each action becomes a plan step with an owner, a team and a due date, and a linked measure shows whether it's working. Leaders see what's done and what's late without chasing anyone.
5
Close the loop and look across RCAs
Send feedback to the person who reported the event, record whether the change held, and look across events by department, severity and tag to find causes that keep coming back.

1
Start from the event
Reviewers create a linked project directly from the safety event, using the ready-made RCA template, so the analysis keeps the original report, its severity and the people involved in its review.
2
Work the causes as a team
The team describes what happened, lists the gaps and the root cause behind each one, and uses tools such as 5 Whys and fishbone diagrams to look past the individual to the system.
3
Choose stronger actions
Each cause gets at least one countermeasure. Your RCA template can prompt teams toward actions that change the design of the work, such as forcing functions and standardized equipment, rather than more training and reminders.
4
Track every action to done
Each action becomes a plan step with an owner, a team and a due date, and a linked measure shows whether it's working. Leaders see what's done and what's late without chasing anyone.
5
Close the loop and look across RCAs
Send feedback to the person who reported the event, record whether the change held, and look across events by department, severity and tag to find causes that keep coming back.

In practice

One fall RCA, from causes to actions ranked by strength

The causes point at the system, not the nurse on shift. The actions are sorted by the action hierarchy, so a plan made only of weaker actions is obvious before it's approved.

Safety event under review

Unwitnessed fall with injury on a medical-surgical unit, night shift; the bed-exit alarm did not sound

Root causes and contributing factors

Bed-exit alarms are easy to leave switched off after care
- The switch sits under the side rail, out of sight
- No alarm-status check at handoff
Two bed models on the unit work differently
- Float staff trained on one model only
- Alarm cables fit one model loosely
Fall-risk status isn't visible from the corridor
- Risk recorded in the chart only
- Night staffing spreads rounding thin

Corrective action plan

Stronger action
Standardize on one bed model with an alarm that re-arms itself
Owner: Director of clinical engineering
Measure: Beds on the unit with auto re-arm
Intermediate action
Add alarm status to the bedside handoff checklist
Owner: Unit nurse manager
Measure: Handoffs with alarm status checked
Intermediate action
Fall-risk signage at the door for at-risk patients
Owner: Clinical nurse specialist
Measure: Audit of signage on at-risk rooms
Weaker action
Brief float staff on both bed models
Owner: Nurse educator
Measure: Float staff briefed

Illustrative example with no patient information. Your teams can adapt the RCA template and set their own causes, actions and measures.

Who it's for

Something useful for everyone involved

Patient safety officers and RCA facilitators: Each RCA linked to its event, with causes, actions and owners in one place instead of a document per review.
RCA team members: A guided template that keeps the focus on the system and the causes, not on who was on shift.
Action owners: Their corrective actions with a due date and a measure, and a clear definition of done.
Risk managers and quality leaders: The status of every open action plan, and the causes that recur across RCAs.
Executives and safety committees: Evidence that actions were completed and are working, not just that the analysis was filed.

What changes

From working around the problem to working on it

Today

RCA write-ups in separate documents
Action plans heavy on training and reminders
Actions tracked in a spreadsheet, if at all
Reporters never hear what the RCA changed

With ImprovementFlow

The RCA linked to the event that started it
Prompts toward stronger, design-level actions
Every action with an owner, a due date and a measure
Feedback to the reporter when the loop closes

Built for how healthcare investigates serious events

Connected to safety reporting: The RCA starts from the safety event and stays linked to it, with the event's severity, reviewers and audit trail of what changed and who changed it.
A ready-made RCA template: ImprovementFlow ships a ready-made RCA template, and your team can customize it without IT, so the sections and prompts follow the RCA² approach or the format your organization already uses.
Secure from day one: HIPAA compliance, a BAA and SSO are included in every package.

Getting started

Your first 90 days

Start with the RCAs already open and the facilitators who run them.

Weeks 1–2
Adapt the ready-made RCA template with your patient safety team, and move open RCAs and their action plans into ImprovementFlow.
Weeks 3–6
Run new RCAs from the safety event, assign every action an owner, date and measure, and review action strength before approval.
Weeks 7–12
Review open actions with leaders, send feedback to reporters on closed RCAs, and look across RCAs for shared causes.

Guides

Guides for RCA teams

Plain-language primers for facilitators and the teams they lead.

Frequently asked questions

What does The Joint Commission expect after a sentinel event?: Under its Sentinel Event Policy, accredited organizations complete a comprehensive systematic analysis, most often an RCA, and a corrective action plan within 45 business days of the event or of becoming aware of it, then implement the plan and monitor whether it works. ImprovementFlow keeps the analysis, the actions and the monitoring on one record.
What is RCA², and can we follow it?: RCA² (root cause analysis and action) is the National Patient Safety Foundation's 2015 guidance for making RCAs lead to effective actions: risk-based prioritization, a small team, stronger actions with a measure for each, and leadership review. Your RCA template can follow its steps and prompts.
How do you keep action plans from being all training and policy?: Build the action hierarchy into your RCA template's prompts, so teams look for a stronger or intermediate action for each cause, and give every action an owner and a measure. Reviewing the plan by action strength makes a plan full of weaker actions visible before it's approved.
Do we have to run a full RCA on every event?: No. Many organizations reserve a full RCA for sentinel and serious events and use lighter reviews for others. The severity and tags on each event help you decide, and any event can still become a linked project when the review shows it needs one.
Can we tell the reporter what the RCA changed?: Yes. Reviewers can send feedback to the person who submitted the event, so a named reporter hears what was done. People who stay anonymous see what happens next when they submit.
What about security?: HIPAA compliance, a BAA and SSO are included in every package.

Bring us an RCA that's still open. We'll show you how its actions get done.

Tell us how your organization runs RCAs today and where action plans tend to stall. We'll walk through one review from the safety event to an action that's measured and closed.

We typically respond within one business day.

Prefer email? info@communify.us

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