CORE-833

CORRECTIVE ACTION

ROOT CAUSE ANALYSIS - 5 WHYs

INTRODUCTION

After conducting a monitoring review, have you ever had a facility that had several findings and the facility was unsure of what to do?

How could you, as a sponsoring organization help the facility figure out how this happened and how it should fix it?

First, let’s recall what a corrective action is.

A corrective action is the action the facility will take within a specific time frame to address the finding(s) of noncompliance and to prevent it from recurring. 

A corrective action is many things. It:

  • 1
    Is new or improved processes or procedures
  • 2
    Is implemented within a specific time frame
  • 3
    Is expected to fully and permanently resolve the condition that resulted in noncompliance
  • 4
    Is expected to prevent recurrence
  • 5
    Identifies who is responsible for implementing and maintaining new processes or procedures
CONTINUE