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©April 2019 Center for Innovative Public Policies, Inc. Root Cause Analysis to Improve Jail Safety: Getting Past Blame Susan W. McCampbell, CIPP, Inc., Naples, Fl., and Mary E. Earley, Douglas County Dept. of Corrections, Omaha, Nebraska What’s Here? Page Ö An Introduction - Root Cause Analysis (RCA) 2 Ö What is Root Cause Analysis 3 Ø What Events Trigger a Root Cause Analysis 4 Ø How is a Root Cause Analysis Different from an Internal Investigation? 5 Ö Why Conduct Root Cause Analysis? 5 Ö Elements of Root Cause Analysis 8 Ö Corrective Action Plans 9 Ö How to Begin? Strategic Plan for Adopting Root Cause 10 Ö Jail Risk Management – Preventing Unspectacular Mistakes 11 Ö Measuring Success through Evaluation 11 Ö Decision Points: How to Conduct a RCA Analysis 12 Ö Obstacles and Overcoming them 14 Ö What’s Next? 15 Ö Resources: 16 Ø Definitions 17 Ø Link to Policies and Procedures 22 Ø Corrective Action Templates 24 Ø Organization of an RCA Report 28 Ø Resources and Bibliography 32 ü Works Cited 37 Thanks are extended to graduates from the National Jail Leadership Command Academy who volunteered to review this document and provide ideas, suggestions, and insights. Thanks also to Mrs. Les S. Dolecal for her assistance.

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Page 1: What’s Here? Page5270]_1.pdfÖ An Introduction - Root Cause Analysis (RCA) 2 Ö What is Root Cause Analysis 3 Ø What Events Trigger a Root Cause Analysis 4 Ø How is a Root Cause

©April2019CenterforInnovativePublicPolicies,Inc.

RootCauseAnalysistoImproveJailSafety:GettingPastBlame

SusanW.McCampbell,CIPP,Inc.,Naples,Fl.,andMaryE.Earley,DouglasCountyDept.ofCorrections,

Omaha,Nebraska

What’sHere? Page

Ö AnIntroduction-RootCauseAnalysis(RCA) 2

Ö WhatisRootCauseAnalysis 3

Ø WhatEventsTriggeraRootCauseAnalysis 4

Ø HowisaRootCauseAnalysisDifferentfroman

InternalInvestigation? 5

Ö WhyConductRootCauseAnalysis? 5

Ö ElementsofRootCauseAnalysis 8

Ö CorrectiveActionPlans 9

Ö HowtoBegin?StrategicPlanforAdoptingRootCause 10

Ö JailRiskManagement–PreventingUnspectacularMistakes 11

Ö MeasuringSuccessthroughEvaluation 11

Ö DecisionPoints:HowtoConductaRCAAnalysis 12

Ö ObstaclesandOvercomingthem 14

Ö What’sNext? 15

Ö Resources: 16

Ø Definitions 17

Ø LinktoPoliciesandProcedures 22

Ø CorrectiveActionTemplates 24

Ø OrganizationofanRCAReport 28

Ø ResourcesandBibliography 32

ü WorksCited 37

ThanksareextendedtograduatesfromtheNationalJailLeadershipCommandAcademywhovolunteeredtoreviewthisdocumentandprovideideas,suggestions,andinsights.ThanksalsotoMrs.LesS.Dolecalforherassistance.

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Introduction

Thistoolkitisintendedtointroduce,orre-introduce,theconceptofrootcauseanalysis(RCA)tohelpjailleadersassessbothcurrentriskmanagementandpreventionstrategies.Whetherfacedwithexaminingacriticalincident,orbeingproactiveinaddressingemerging

issues,RCAisaviableinstrument.Waitingfora“spectacular”incidentbeforeexaminingoperationsisanirresponsiblewayofdoingbusiness.Theconsequencesoferrormaybeperceivedasminor.Forexample,aninmateincourtmisseshermedication;totragedy,ifthatmissedmedicationwasapatternthatcontributedtoanegativemedicaloutcome.Failuretocollect,analyzeandactondataitselfcreatesormagnifiesharmandsafetyrisks.

“Isitpossiblethatthecurrentera,definedbyepisodicpatchesmotivatedbyhigh-profiletragedies,willbereplacedbyanewperiod,dedicatedtothesustainedpracticeoflearningfromerror?”(Doyle,LeaningfromErrorinAmericanCriminalJustice,2010).Althoughthissentencewaswrittenaboutreformassociatedwithwrongfulconvictions,thesentimentappliesaswelltotheunevenwayinwhichjailsseektotrulyunderstandincidentsandeffectivelyimplementreforms.Doyleaskswhencriminaljusticepractitionerswill“...mobilizethe

experiencesofmedicineandaviationinblazingtheirowntrailstowardacultureofsafetytoilluminatewhatmaydevelopfromthecriminaljusticesystem’seffortstolearnfromerror.”(Doyle,LearningfromErrorinAmericanCriminalJustice,2010)Jailmanagerswillbebetterservedtoleadfromaproactivepositionbeforeincidentsoccurratherthanwaitingfora

crisistoleadthem.“Thecontemporarycriminaljusticesystemlacksaroutineforidentifyingandanalyzingitsunspectacularerrorsandatemplateforreportingtheirlessons.”(Doyle,LearningfromErrorinAmericanCriminalJustice,2010)Thistoolkitisintendedtohelpjailleaderscreateandinstillmethodsforassessmentofcurrentprocessesbefore,duringandafterincidents.Withanumbingsenseofdéjàvu,somejailsseemtorunonadrenalin;staggeringfromonecrisistoanother.Oftenjailsdon’tseetheearlywarningsofpolicyfailure,orlapsesinsupervisionortraining–untilitistoolate.Preventioninitiatives,reviewofeventstodiscernpatternsandtrendsandaddressthefixesareperceivedasextravagancesand/ornotsupportablebycurrentpolitics,resources,ortheinternalculture.Whileaninternalaffairsinvestigationmaybedonetoidentify,or“blame”whowasresponsibleforanincident,preventionandsustainablechangeareoftennotapriority.Yet,doesthisphilosophyofjailoperationskeepstaffandinmatessafe,and/orinspiretheconfidenceoftheemployees,thecommunityandfunders?

“Criminaljusticepractitioners...rankandfilehavebeentaughtthroughouttheircareersthatsilenceonthematter[oferrors]isusuallythesafestpolicy.”(Doyle,LearningfromErrorinAmericanCriminalJustice,2010)

“[B]lameandfaulthaveneveransweredthebigquestions,suchas‘Howdidthis[error]happeninthefirstplace?’”

(Ritter,TestingaConceptandBeyond:CantheCriminalJusticeSystemAdoptaNonblamingPractice?,2015)

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WhatisRootCauseAnalysis(RCA)?

TheobjectivesofRCAaretocreateandsustaina“cultureofsafety”separatingsymptomsfromcoredeficiencies–includingthattheorganization:“(1)isinformedaboutcurrentknowledgeofitsfield;(2)promotesthereportingoferrorsandnearmisses;(3)createsanatmosphereoftrustinwhichpeopleareencouragedtoreportsafety-relatedinformation;(4)remainsflexibleinadaptingtochangingdemands(by,forexample,shiftingfromsteeplyhierarchicalmodesinto“flatter”team-orientedprofessionalstructures);and(5)iswillingandabletolearnaboutandadjustthefunctioningofitssafetysystem.”(Reason,1997)TheultimateobjectivesofRCAareproblem-solving,reductionofriskandpreventionoffutureoccurrencesofadverseeventsthroughimplementingmeasurableandtime-drivenaction-plans.RCAisatransparent,collaborativeprocess,occurringafterasentinelevent,orutilizedtoaddressanemergingoperationalchallenge,to:• identifythepolicy/procedure

disconnectortheemergingchallenge;

• gatherdata;• thoroughlyanalyzetheevent

(sometimeslabeledas

determiningthe“5Ws–whowhatwhen,where,why);

• determinecausation;• articulaterecommendations;

and• developandimplementa

correctiveactionplan.

RCAisatoolforjailsinatleasttwoareas.First,RCAcanbeusedtodissectanincidentoreventhappeninginthejail.“Asentineleventisasignificant,unexpectednegativeoutcomethatsignalspossibleunderlyingweaknessesinasystemorprocess;islikelytheresultofcompounderrors;andmayprovidekeystopreventingfutureadverseeventsoroutcomes.”(U.S.DepartmentofJustice,NationalInstituteofJustice).Sentineleventsshouldserveasearlywarningsofpendingadverseevents.Secondly,administratorscanuseRCAtolookatemergingissues,orperceivedbarrierstojailoperationsbeforeacrisisorevent.Forexample-RCAcanexaminethecausesforemployeeattrition,physicalplantdeficiencies,ortrendsinincidentsamonginmates.Thisistrueriskavoidance–forthemoreissuesthatcan

PrinciplesofRootCauseAnalysis(RCA)• Focusingoncorrectivemeasuresofroot

causesismoreeffectivethansimplytreatingthesymptomofaproblemorevent.

• RCAisperformedmosteffectivelywhenaccomplishedthroughasystematicprocesswithconclusionsbackedupbyevidence.

• Thereisusuallymorethanonerootcauseforaproblemorevent.

• ThefocusofinvestigationandanalysisthroughproblemidentificationisWHYtheeventoccurred,notwhomadetheerror.

(WashingtonState,n.d.)

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beidentifiedbeforeanevent,themorelikelynegativeoutcomescanbecircumvented.Theprocessalsohelpsidentifywhatthejailmissedaswarningsignsbeforetheincidenthappened.Mostjailshaveaprocessbywhichaseriousincidentisreviewed.ThequestioniswhetherthatprocessresultsinidentifyingtheROOTcause(s)andwhetherthejailtakesmeaningfulandsignificantactiontopreventanotheroccurrence.Whethertheprocessiscalledacriticalincidentreview,sentineleventreview,after-actionreport/critique,operationalaudit,factfinding–thedesiredoutcomeshouldbethesame–prevention.Asecondaryandseparateissueisemployee-relatedactions,andassignmentof“blame”oremployeeresponsibility.Jailstaffmayhaveheardtermsemployedbythefacility’shealthcareproviderthatspeaktoself-criticalreview.Theseterms,definedhereininclude:continuousqualityimprovement(CQI);morbidityandmortalityreview(M&M);qualityassessment(QA);andqualityimprovement(QI).Suchtermsandpracticesareintegralcomponentsofanorganizationseekingself-improvementandreductionofharm.AnRCAisNOTintendedtobeaninternalaffairsinvestigation.TheRCAlooksatprocess,policies,procedures,training,supervision,etc.,whileaninternalaffairsinvestigationisoftenseekingtofocusonemployeebehaviors.Thesearenotmutuallyexclusiveprocesses.Theagency’spolicymustdefinetheroleofeachandhow,andif,theprocessescoalesce.

WhatEventsTriggeraRootCauseAnalysis?Ajail’spolicywilldefinewhenRCAsareconducted.AnRCAlooksatmorethanjustthecauseofanevent.Itmustexaminesystemsissuesandhighlightpreventionactions.Forexample,aninternalreviewofanescapefromcustodymightfindthatalockwasdefective,butadeeperlookattheincidentmayreveallapsesinsecuritychecks,delaysinrepairs,budgetissues,trainingissues,and/orsupervisoryissues.Inthisexample,justfixingthelockmightnotpreventarecurrenceoftheevent.Focusingonbreakdownsinsystemsoroperationsiswhataddressesprevention,EventsrequiringactivationofaRCAshouldalsobeincludedinthejail’spolicy.Triggeringeventsmayinclude:Ø In-custodydeathorseriousself-

harmØ EscapesØ InmatedisordersØ Inmateback-upsinbooking,and

relatedoperationalchallengesØ Housingshortagesforspecial

populations

RCAscanalsobeusedtodrilldownintoemergingissuesbeforethesebecomeincidents.Forexample,whentherearedocumentedrecoveriesofdangerouscontraband–suchasopioids-examiningtheissuesbeforethereisharmtoaninmateorstaffwillbebeneficial.OtheremergingchallengeswhichmighttriggeranRCAinclude,butarecertainlynotlimitedto:Ø Usesofforceinvolvinginmateson

thementalhealthcaseloadØ Introductionofcontraband

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Ø CompromisedsecuritysystemsØ MandatoryovertimeØ EmployeerecruitmentorretentionØ PhysicalplantissuesØ StaffsexualmisconductØ Theimpactofthecommunity’s

opioidcrisisonthejailDevelopingasimpletrackingmechanism,withmonthlyorquarterlyreviewsofthesetypesofoccurrenceswilllikelyhighlightwhereattentionisneeded.Itisthejail’sdecisionastowhatwilltriggeraRCA.HowisaRootCauseAnalysisDifferentfromanInternalInvestigation?Generally,traditionalinternalinvestigationsfocusonfindingthepersonsorconditionsresponsibleforanevent.Investigatingsuspiciousactivitiesandactinguponallegedviolationsofpoliciesbyinmatesorstaffistheprimaryobjective.Internalinvestigationsaretypicallyreactive;andwhileRCAscanalsobereactive,theRCAgoalistoachievepro-activebenefits.Whileinternalinvestigationsmayincluderecommendationsaimedatprevention,suchasremedial/correctivetrainingwheremisconductisfound,theseinvestigationsoftendonotdrilldownintowhethertherearelargersystemsissues.RCAsareintendedtoexaminemanyofthesameissuesregardinghowtheincidenthappened,buttheRCAisnotintendedtoassignblame.TheendgoaloftheRCAistopreventfutureincidents. BothinternalinvestigationsandRCAshaveadefinedroleintheorganization.Aspoliciesaredeveloped,careneedstobetakeninassuringthatthetimingofRCAsdoesnotcompromiseinternalinvestigationsthatmightresultin

negativepersonnelactionsand/orcriminalprosecution.Deliberatelyconductingparallelreviews–internalreviewsandRCAs,withinpredeterminedpolicyguidelines,isanoptionforthejail. ViewingsamplesofRCAshighlightedintheBibliographyandResourcesectionofthistoolkitwillhelpfurtherdefinetherolesofbothactivities.WhyConductRootCauseAnalysis?Introducingorupdatingaself-criticalreviewprocesssuchasRCAmayrequireeducationandgainingbuy-infromemployees,stakeholders,fundersandthecommunity.Herearesomepositiveoutcomesthatcanemergefromanagency’scommitmenttoRCA.

Ø Establishescommitmentto

excellencethroughobjectivereviewsofseriousincidents,examinationofemergingissues,anddevelopmentandimplementationofchangestrategies.Aspubliclyfundedagencies,jailshaveanobligationtobeaccountabletothecommunity.RCAprovidesthevehicletodothis.Jailscan’thaveitbothways–lamentingthecommunity’stepidsupportofthejailandlackofresources,whileatthesametimefailingtobeforthcomingandtransparentwhenaseriousincidenthappens.(McCampbell,OrganizationalAccountability:TheRealBreakfastofChamptions,2016)

Ø Establishesacultureof“...non-

blaming,forward-thinking,all-stakeholderapproachtoimprovingcriminaljustice

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outcomes.”(Doyle,NIJ'sSentinelEventsInitiative:LookingBacktoLookForward,2014)The“blamegame”isoneobstacletocreatinganenvironmentformeaningfulself-criticalanalysis,preventionandproblemsolving.Thoseoperatingjailsworkin“...aninherentlypoliticalcontext”withpotentialnegativeoutcomesofpublicscrutinyandcriticism.(Ritter,TestingaConceptandBeyond:CantheCriminalJusticeSystemAdoptaNonblamingPractice?,2015)Transparentreviewofsentineleventsgoesalongwayinmaintainingcredibilitywiththepublicandinthepoliticalrealm.Preventingthemcertainlyreducesscrutiny.

Ø Rolemodelingleadership

expectations.Jailsleadersleavealegacy–whetherpositiveornegative,soughtorunearned.Thatlegacyisevenmoreapparentinemergenciesandcriticalincidents.Employees,inmates,andthecommunityobservehowtheleadermanagesinverydifficulttimes.Thisthensetsand/orredefinesthefutureoftheorganization.

Ø Identifiessystemfailures.(U.S.

DepartmentofHomelandSecurity,U.S.FireAdministration;NationalFireDataCenter,FederalEmergencyManagementCenter,2008)ThegoalofconductingaRCAistofindsystemsfailures.“Systems”orprocessesarewhatjailsputinplacetoachievethemission.Often,wecreateredundantsystemssothatifonefails,theback-upsystemwillflag

andaddressthematter.Sometimestheseprocessesarepeoplefocused;sometimeshardwarefocused;butquiteoftenareacombinationofboth.Thereisfrequentlymorethanonecauseofanincident,henceafailedsystem.Systemsmayfailbecausestaffareuntrained,processesnotwrittendown,supervisorsareineffective,orpeoplejustdon’tdotheirjob.TheRCAistolearnmoreabouttheunderlyingissues.

Ø Examiningfromaglobal

perspective.BorrowingfromtheNationalTransportationSafetyBoard’s“GoTeam”investigations–aviationaccidentsareexaminedfromawideview–thehistoryoftheflightandcrewimmediatelypriortothecrash,theairframe’sintegrity,thecraft’spowerplant;theaircraft’shydraulic,electrical,pneumaticsandassociatedsystems,communicationfromairtrafficcontrol,weather,humanperformanceandsurvivalfactors.Justknowingthattheweatherwasbadisinsufficienttoassesstheaccidentandfocusonprevention.(NationalTransportationSafetyBoard,n.d.)

Ø Providesaframeworkforreview,

assuringthatdataandstepsintheprocessarenotmissed.(WashingtonStateDepartmentofEnterpriseServices,n.d.)Ajail’scommitmenttoconductingtransparentreviewsofincidentsrequiresaframework.Thisframeworkprotectstheprocessfromthosewhomaynotbehappywiththepotentialresults,andprovidescredibility.

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Ø Evaluatestheeffectivenessof

policies,procedures,protocols,supervisorypractices,training,andleadership.Evenifajailperiodicallyandsystemicallyassessesoperations,andupdatespoliciesandprocedures,anadverseoutcomewillmostlikelyresultinamoredetailedreview.Theprocessofevaluatingfoundationalprovisionsusingastructuredframeworkwillimprovetheorganization.Addressingthe“blaming”culturenotedabove,thefocusisonprocessesNOTpeople.

Ø Documentstrendsandpatternsin

operationalerrors.Whileseeingthesameerrorsrepeatedtoooftenmightbetheresultoffocusingonsymptomsratherthanthecause,steppingbacktoidentifyandexaminepatternswillhelpdefinesolutions.Jails’decision-makingshouldbedata-driven.Ifsolutionshavebeenpreviouslyattempted,whydidthosenotwork?Whatarethebarrierstoapermanentsolution?Howeffectiveistheriskmanagementsystemwhenconsideringtheadverseevent?

Ø Servesasaplatformforchange.

Thefirststepinthechangeprocess,accordingtoJamesP.Kotter,isestablishingasenseofurgency.(Kotter,1996)Itisconcerningthat,insomeorganizations,changeonlyhappensafteranadverseincidentisairedonthesixo’clocknewsandonsocialmedia.

Ø Separatessymptomsfromthedisease.Asactionorientedorganizations,jailsarequicktoreacttonegativeoutcomes,butoftendonotspendtimefiguringouttheunderlyingissuesthatcausedanincident.Leadersareoftenleftwonderingwhythe“fix”didn’twork.TheRCAprocessfocusesonunpeelingtheeventtoitscore.

Ø Otherpositiveoutcomes:o Tracksissuesconsidering

adequatefunding,assistswithbudgetaryprioritization.(Zarnescu,2017)Thecompetitionforfundinginanycommunityisintense.Localpoliticalleadersmustchoosebetweencompetingandcompellingpriorities.Delayingpreventivemaintenanceofajail’ssecuritysystems,whichmayhavebeenacontributingfactortoanescape,couldbeanopportunityfor“toldyouso”fromthejail’sleaders.Moreproductively,itprovidestheframeworkforsurfacingandaddressingtheentirephysicalplantstatus.TheRCAprocessispartofthatfoundationalwork.(McCampbell,CoreCompetency:Comprehend,ObtainandManageFiscalResources,2016)(McCampbell,ThePhysicalPlanandInfrastructure:TheJailLeader'sResponsibilities,2016)

o Identifiesemergingcommunitytrendsandissues.Thepublicdoesnotviewjailsaspartofthecommunity’slawenforcement/publicsafety.Jailsmustbeactiveinidentifyingandtrackingcommunitychanges.Themost

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profoundexamplesaretheevolutionofjailsintothecommunity’sdefactomentalhealthhospital,andtheimpactoftheopioidcrisis.RCAsprovidetheopportunitytoengageincommunityresearch,identifyingstakeholders,andcommunity–wideproblemsolving.Withoutthecommunity’sknowledgeandsupport,jailswillstruggletosolvetheissueofincarcerationofthementallyill.

o Identifiespositiveoutcomes.Jailstafffeelunderappreciatedinthebestoftimes.Incrisis,whenthecommunityisscrutinizingthefacility,accuratelyidentifyingwhatwentwellandwhocontributedarehelpfultobooststaffmoraleandpublicopinion.

ElementsofaRootCauseAnalysis

Thejail’swrittendirectivesandpoliciesdefinewhateventsTRIGGERanRCAandthenecessarycomponents.Amongthefirststepsare:assemblingateam,gatheringinformation,brainstormingcontributingfactors,identifyingrootcauses,writingandimplementingacorrectiveactionplan,andassuringtheplaniseffective.(CaliforniaCorrectionalHealthCareServices,April2013)Notmeanttobeanexhaustivelist–hereareelementsoftheRCAPROCESS.Eachjailmustevaluatetheelementsandincorporatethemintotheirowninternalstrategies.Abovealltheprocessmustbesystematicandnotbederailedbypolitics,relationships,orpredeterminedconclusions.

ThegoalsofRCAaretodetermine:• Whathappened• Howithappened• Whyithappened• Howcanitbepreventedand/or

improved(correctiveactions)?• Whatwarningsignsweremissed?Toconductacrediblerootcauseanalysis–hereareadditionalelementstoconsider:• Developthepreliminaryplan–whois

todothework,whoistoassist,whatisareasonabletimeframe;revisetheplanasneeded.Besuretokeeprecordsofmeetings,attendees,andassignments.Assuredocumentsaresecurelyandconfidentiallymaintained.

• Determinewhathappened(ifthereisanimmediate,urgentneedforaction–don’twaittoreport).

• Establishthefacts;gatherthedata,evidence,information,interviews,video,examineexistingaudits,inspections,etc.,actpromptlysothatinformationdoesnotgetmisplacedordisappear.

• Identifyissues,conditions,andeventsthatcontributed–perhapsusingtechniquessuchaschartingormapping;drilldowntoassurethatactualcauses,notjustthesymptomsareidentified.

• Assurecontributingfactorsareidentified.

• Comparefindingstorelevantpolicies,includingtraininglessonplans.

• Identifytherootcauses,keepasking“why”;aretheissueshumanfactors,communications,training,staffing,scheduling,environment,equipment,rules,policies,procedures?

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• Avoidhindsightbias.Youonlyknowwhatyouknowasanincidentunfolds.

• Startwiththeproblemnotthesolution.Assumptionsand“fixing”canhamperthroughanalysisofcauses.

• Developspecificrecommendations;brainstorm;discussrecommendationswiththoseinvolved.

• Writethereport;aligncauseandeffect,bespecificandfactual,focusonincident.

• Developcorrectiveactionplan(s)and/orafteractionreport(basedonjail’spolicy).

• Discussindividualstaffaccountability(leaveemployeedisciplineandcommendationstoothers).

AchallengingrealityinconductingRCAaretheinfluences,positiveornegative,offorcesoutsidethejail.Forexample:Duringtherootcausereviewofanescape,corrodedlockingmechanismsareidentified.Thedrill-downmustincludeaskingtoughquestions.Istherootcausedueto:theabsenceofajailinspections/audits;failureofsupervisorstoidentifyand/orreporttheproblem;thejail’sfailuretoreviseoperationstoaddressthesecurityissue;thejail’sfailuretoappropriateavailablefundstofixthelocks;thejail’sfailuretoaskforfundingforanidentifiedsecurityissue;orthefundingauthority’sfailuretoappropriatefundstofixtheproblem?Thissimplisticexampleofdrill-downdoesnotseekto“blame”thepersonswhomaybeinvolved;ratheritlooksatthecausewithaneyetowardprevention.Amorelikelyscenarioforajailwillrequiredcollaborationwiththemedicaland/ormentalhealthcareproviders,ormedicalexaminer,foreventssuchasself-harm,suicidesandothernegativemedical

outcomes.Knowingthisisinevitablepresentsanopportunityfordiscussionsandexpectationspriortoanincident,addinglanguagetothejail’swrittendirectiveand/ortheprovider’spolicies.

CorrectiveActionPlans FindingsandrecommendationsflowingfromanRCAarepositiveonlyifincorporatedintoarealisticandtimelycorrectiveactionplan.Therearemanyformatsofcorrectiveactionplans.Theessentialingredientsare:• Specificactionswilloccurinclear,

objective,measurablestatements.• Identifywhowillcarryoutthese

actions;includeotherswhoneedtobeinvolved.

• Establishtimelinesordeadlinesforcompletionofactionitems.

• Identifyresourcesneededtocarryoutchange(s)

• Explainhowtheprocessbetransparentanddefinehowitwillbecommunicatedtostaffandoutsideentities

FiveRulesofCausationRule1:ClearlyshowthecauseandeffectrelationshipRule2:Usespecificandaccuratedescriptorsforwhatoccurred,ratherthannegative&vaguewords.Rule3:Identifytheprecedingcause(s),nothumanerror.Rule4:Violationsofproceduresarenotrootcauses;theymusthaveaprecedingcause.Rule5:Failuretoactisonlycausalwhenthereisapre-existingdutytoact.(CaliforniaCorrectionalHealthCareServices)

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• Periodicmonitoringreportstoleadershipandmanagementwithupdatestotheplanasnecessary.

• Evaluate/determinewhethertheplanresultedinthedesiredoutcome,whyorwhynot.

ThereisnoidealwaytoconductanRCAandthereisnotonepreferredformatforacorrectiveactionplan.Ifajailwholeheartedlyandsincerelyadoptsthisapproach,theremustbediscussion,debateandcollaborationtoarriveattheiruniquestrategy.Wholesaleadoptionofanotheragency’spolicieswilllikelynotfitthefacility’sspecificneedsororganizationalstructure.Aspartofthisprocess,theinternalculturemustbeidentifiedandaddressedascontributorsordetractorsofsuccess.Finally,thisisanEVOLVINGprocess.Itisalearningenvironmenteachtime.Howtobegin?StrategicPlanforRootCauseAnalysisWhenajailwantstoadoptRCAandcriticalself-assessmentaspartofitsoperationalpracticeconsider:• Discussionandconsensusamong

theleadershipofcommitmenttotheprocess,including

identificationofstrengths,weaknesses,opportunities,challenges,andbarriers;

• Consultationwithlegalcounselandinsurancecarriers;

• Communication/orientation/educationtoallemployeesabouttheinitiativeandwhatitmeanstothem,withperiodicupdates;

• Designationoftasks,withtimelines,andreviewprocessestoupdate,refineandimplement;

• Assessmentofinternalcultureandplanstoaddresschangingany“blaming”culture;

• Identificationofresourcesneededtodevelopandsustaintheinitiativeandhowresourceswillbeobtained;

• Dialoguewithboththejail’sinternalandexternalstakeholders(e.g.community,funders)aboutthemeritsofRCAandthejail’sproposedstrategies;and

• Plansforon-goingcollective,transparentoversightastheprocessbegins.

InitiatingaRCAprocessbeginsdeliberately,withplanning,assignments,accountability,andtimelines.

SMARTMODELIndefiningactions,consider:S–Specific–Isthewordingpreciseandunambiguous?M–Measurable–Howwillachievementsbemeasured?A–Action-oriented-Isanactionverbusedtodescribeexpectedaccomplishments?R–Realistic–Istheoutcomeachievablewithgivenavailableresources?T–Time-sensitive–Whatisthetimeframe?

(FEMA,2010)

“...jailriskmanagementcomesdowntothreekeyobjectives:(1)protectingthesafetyofthecommunity,inmates,jailpersonnelandvisitors,(2)preventingpropertydamageandloss,and(3)preservinginmaterights.Ultimately,thechallengeistoachievethefirstandsecondobjectiveswithoutcompromisingthethird.”

(Reiss)

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JailRiskManagement–PreventingUnspectacularErrorsAsthejailconsidershowtoimplement(orupdate)RCAandcorrectiveactions,awordaboutprevention.Simultaneouslyadoptingariskassessmentapproachmaymitigatetheneedforpost-incidentreviews,bypreventingeventsfromoccurringinthefirstplace.Resourcesdevotedtopreventioncanpotentiallysavetime,money,andimprovethesafetyofstaff,inmatesandthecommunity.(McCampbell,CoreCompetenciesforJailLeaders:ReduceJail-RelatedLiabilities,2019)Thisapproachrequirescollectingmeaningfulandaccuratedataaboutjailoperations,analyzingandtrendingtheinformation,andmostimportantlyusingthisdatatoinformdecision-makersonalllevels.(McCampbell,CoreCompetenciesforJailLeaders:OrganizatiionalAccountability,2016)HowcanRCAbeappliedinprevention?Hereareafewideas:• Increasingamountsofcontraband

discoveredduringinspections.Whatisthespecificcontraband,thepossiblesourcesandpreventionstrategies(e.g.hardeningtargets,training,supervision,inmateeducation)?

• Employeeshortagesandresignations.Thereisacontinuingupwardtrendinemployeeshortagesandresignations.Why?Arethererecruitmentdeficiencies?Backgroundprocedures?Training?Supervision?Pay?Whataretherealissueandpossiblesolutions?

• Inmate/inmatealtercations.Incidentsareincreasing,alongwithusesofforce.Whereandwhattimeisthishappening?Whatarecommonelements?Isittraining,supervision,classification?Whatisthecorereason(s)?Whatareoptions?

• Grievancesareupforfoodservice.Whataretheunderlyingreasons?Hastherebeenachangeinpractices,menus,suppliers,supervision,providers?

• Newarresteesarebackingupinbooking,especiallyonweekendnights.Whatcanbedonetomovearresteesmoreexpeditiously?

• Thestatelegislatureisconsideringnewlegislationtorequirejailstoholdinmatesforthreeyears,insteadoftransferringthemtostateprisonaftersentencing.Whatwillbetheresponseinyourjail?Whatoperationalpracticeswillneedtobechanged,whatcostswillbeincurred?

TheideasofhowtouseRCAforpreventionarelimitless.Ashiftinthinkingatthejailleadershiplevelmovesawayfromwaitingforsomethingbadtohappenandreacting–tousingdatatoexamineemergingissues,payingattentiontotheexternalenvironmentandpreventingincidents.Thisprocessalsorolemodelsthebehaviorsdesiredfromtheemerginggroupofjailleadersfrom“firefighting”toproactiveproblemsolvers.MeasuringSuccessthroughEvaluationAftercompletionoftheRCA,reviewofallinformationanddevelopmentofanactionplan,jailleadersmayimplementchangestothephysicalplant,processesorpolicytopreventrepetitionofanevent.

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IncorporationofformalorinformalevaluationsandfocusonassuringcorrectiveactionplansarecompletedaspartoftheoverallRCAstrategicplanwillensureimplementedchangesarecompletedasintended.Monitoringsuccessandensuringstaffarecomplyingwithrecommendedchangeswillbenecessarytoensureitisfullyincorporatedintoday-to-dayoperations.Continuingdatacollectionandreviewcanidentifyiftrendsareimpactedbychangesmade.

DecisionPointsUpdatingorImplementingRootCauseAnalysisThistoolkitdoesnotprovidea“model”policy,butratheroutlinesthedecisionpointsforthejail’sleadershipregardingupdatingorcreatingrelevantwrittendirectives.Theseconsiderationsareborrowedfromthefieldsofmedicine,corrections,lawenforcement,emergencymanagement,andfireservices.Thistoolkitprovideslinkstopoliciesandproceduresinthesefields.Acriticalunderlyingpremiseofthisworkisthatthejailidentifies,collects,andanalyzesdataaboutoperations,andthatthisdataisaccurateandcredible.Thisdocumentisintendedtospurdiscussioninyourjail.Leadershipmayhaveadditionaldecisionsthatneedtobemade,anduniqueconsiderationsastheprocessmovesforward.Thesearenotarrangedinpriorityorder,andtheexactprocesswillunfolddifferentlyineachjail.

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DecisionPoints–Revisingand/orImplementingRootCauseAnalysisinJails

Issues Consideration(s)Isthereanexistingdirectivethataddressescriticalincidentreviews,RCA,correctiveactionplans?Ifso,whenwasthelasttimeitwasupdated?Doestheprocessproducetheresultofimprovingsafetyandsecurityofthejail?Dostaffbelieveintheprocess?Aretheretangibleresults?Areriskassessmentsandauditsroutinelyconducted?Isthedatacollectionsystemrobustandaccurate?

Ifacurrentprocess/directiveisinplace,doesitworktoimprovesafety?Arecorrectiveactionplansimplementedanddocumented?Ifthereisnoguidingdirective,oracompleteone,whataretheelementsimportanttotheorganizationandstakeholders?Determinehowroutineinspections,audits,etc.arepotentiallyintegratedintoRCAs.ReviewofcompletedRCAspreparedbyotherjailscanprovideinformation.

Whatisincludedinthedefinitionofatopic/subject/eventthattriggersanRCA?Aretheredefinitionsonwhichallcanagree?Aretheyclear?

Aresentinelevents,criticalincidents,currentpressingissues,opportunitiesforchange,patterns,trendssupportedbydata?Willthisbeproactive,reactive,orboth?Haveanalysesofincidentsinthisjailbeenaccurateandresultedinpositivechange(notjust,forexample,employeediscipline)?

WhocaninitiateanRCA?Whenistheprocessbestdonebyanexternalentity?

AreRCAsonlyatthecommandlevel?Istherebenefitforusingthisasatoolthroughouttheorganization?Ifso,whatarethereportingrequirements?

Where,organizationally,istheresponsibilitytoinitiate,delegate,research,prepare,reportfindings?Whereistheresponsibilityvestedfordevelopingcorrectiveactionplans,andfollowingthrough?

Isthereabenefittodelegationtotrainedpersonnel?Isthisanopportunitytodisplaydecentralization?

Communication–whoareresponsibleforcommunicatinganyneworrevisedRCAinitiativeto:fundingauthority,communitystakeholders,employees,contractors?Whocraftsthemessageandwhofollows-through?

Iftheinternalcultureisnegativeand/oruntrustingofself-criticalreviews,whatspecificsneedtobeaddressed?If“blaming”istheculture,whatneedstobeintroducedtochangetheperceptions?

Whatisthepositionofthejail’slegalcounselandinsurancecarriersregardingconductofanRCA?

Educationaboutwhyrootcauseidentificationisnecessary(asopposedtoidentifyingsymptoms).Whatiscommongroundintermsofimprovingjailsafety?

Resources–whatresources(humanandother)arenowdevotedtoaudits,reviews,inspections,etc.?Canthisbeintegratedwith,forexample,PREArequirements?

Arethereopportunitiesforconsolidationoffunctionsandrelevantcostsavings?

SkillSets–arestaffwhowillprepare,conduct,reviewandeditsufficientlyskilled?Isthereateam?Whoistheteamleader?

Thereisacosttohavingunskilledoruntrainedstaffinvolved,theleastofwhichisdemoralizingthoseinvolvedandjeopardizingcredibility.

InternalStakeholders Whoneedstobeinvolvedasinternalstakeholders?Collectivebargainingunits,employeeorganizations?

ExternalStakeholders.Doesthejailhavecredibilityinthecommunity,amongfunders,andwithitsownstaffintermsofbeingproactiveandresponsivetocriticalincidents?

AnhonestassessmentmayhelpplanfortheimplementationofRCA;notingthebenefitstostakeholders,staff,etc.

Afterconsiderationofthesefactors,doesleadershipcommit(orrecommit)totheRCAprocess?

Ifthereisnotleadershipcommitment,perhapssetasidetoanothertime.

StrategicplantoimplementRCA.Developatimetable.Identifyresourcesandtalent.

Considerhowstaffmightreceiveorientationand/ortrainingnotonlytodevelopbutimplementRCAs.Whoamongstakeholdersand/orotherpublicsafetyagenciescanassist?

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Issues Consideration(s)Whowillreviseordraftthedirectivegoverningtheprocess?Whatisthetimetable?

Whathelpisavailable–fromotherjails?RememberthathealthandmentalhealthagencieshavebeeninvolvedwithRCAforyears,andmayassist.

Theprocess–howwilltheRCAunfold? Seeabove–ElementsofRCAWhoisresponsibleforimplementingandaccountabilityforcorrectiveactionplans?

Whatistheagencycommitment?Isthereanevaluationofhowwellthecorrectiveactionplanworked?

Annualreviewofthepolicyandannualriskassessments–whatdidthejaillearn?

Howcantheprocessbeimproved?

Communication–inthecommitmenttotransparency,whatelementsoftheprocessaresharedwithemployees,stakeholders,media,fundingauthority?

Whatarestatestatutesguidingrelease,andwhatistheinputofthejail’slegalcounsel?

Documentation–howhasthisjailimproved?Beenmadesafer?Betterallocatedandspentfiscalresources?Gainedtheconfidenceofstaffandthecommunity?

Thereisdirecttangible(e.g.costsaving)andintangibleresults(e.g.lowerstaffattritionrates).Howcanyouquantifytopaintthepictureofthejail’simprovements?

ObstaclesandOvercomingThemTherearechallengestoimplementingandsustainingacredibleRCAprocess.Amongtheseare:• Absenceofauthenticleadership

commitment;• Internalagencyculturewhichdoes

notacceptcriticalself-assessmentandischaracterizedby“blaming”ratherthanfactfindingandcorrection;

• Fearoffindings/outcomes;• Absenceofgoverningpolicies,

procedures,andformats;• Lackoftrainingonhowtoaccomplish;• Nofollow-throughonfindingsor

actionplans,thusunderminingthecommitment;

• Concernsoflegalcounsel;and• Resources.AspartofthestrategicplanningprocesstoreviseorimplementaRCAprocess,theleadershipmayhaveidentifiedotherchallenges,andgainstakeholderbuy-in–includinglegalcounsel.

Strategiestoaddresstheobstaclescanbedevelopedaspartoftheplanningprocess.Nooneknowsyourjailbetterthanyouandthepeoplewhoworkinit.Communicatingideasaboutthisinitiativemaybringsupportersanddetractorsforward.Listeningtotheseconcernsareimportant,butwithaneyetowardssolvingtheissue,ratherthanallowingthesetobecomebarriers.Thismonographdoesnotintendtominimizetheconcernsofthejail’slegalcounselasabarriertoimplementingacredibleandrobustRCAprocess.Thereisrealinherentconflictbetweenthejail’sneedtoidentifythecausesofanincidenttopreventitfromhappeningagain,andlegalcounsel’sdesiretoprotectsuchinformationfromdiscoveryintheeventoflitigation.Alegalreviewoftheconceptsandlitigationassociatedwiththe“self-criticalanalysisprivilege”arebeyondthescopeofthiswork.Referencesareincludedinthebibliographythatdirectthejailleaderandlegalcounseltoadditionalinformation.

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Canajailcrediblyoperateifitfailstodrilldownintothereasonsforharmanddoesnottakecorrectiveaction?Thejailadministratormustaddressthismatterwiththeircounsel.Ratherthanfurtheringaconflict,identifycommongroundandmakecollaborativeeffortstoassurefuturejailsafety.Dependingonthephysicallocationofajail,astateorFederalcourtmayhavealreadyruledonanyprivilegethatmayexisttoprotectbonafidereviewsconductedbyajail,consistentwiththeirinternalpoliciesandprocedure.(JonesJ.,2003)

Thebalancingofthecompetinginterest–preventionoffutureharmtostaffandinmates,versesprotectionofnegativeRCAfindings–requireconsensusonthefutureofthejail’soperations.Yourstate’sopenrecordlawsand/oradministrativeregulationsalsoinfluencedisclosureofjailrecords.Failuretothoroughlyreviewincidents,developandimplementcorrectiveactions,placesthejailatriskofbeingperceivedasunresponsive,orworse,

deliberatelyindifferent.Finding“blame”isonlyonepartofthejail’sobligation.

Whatarethebarriers?TheNJLCAgraduateswhoreviewedthisdraftdocumentwereaskedtoidentifyallthebarrierstheysawtoconductingrootcauseanalysisintheirjail.Theresponseswere:• 83%-lackofinternalknowledge,skillstoconduct• 50%-lackofpolicyandprocedure• 25%-lackoftime• 25%-notapriority• 25%-concerns/fearoffindings• 8%-absenceofsupportfromthefundingauthorityNooneidentifiedlackofsupportfromlegalcounsel,orlackofsupportfromtheinsurancecarrierasabarrier.Onerespondentnotedthatthereviewswhichareconductedaremore“patrol-centric”anddon’talwaysreflectknowledgeofcriticaljailissuesoroperations.

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What’sNext?Thistoolkitisintendedtofurtherdiscussionforjailsaboutseekingandmaintainingasaferenvironmentthroughadoptingacultureacceptingofcriticalself-assessmentandgettingtotherootofproblems/incidents/emergingtrends.Examiningacrisis,orpendingcrisis,iscrucialtosafety,butrequiresacommitmenttocorrectiveaction.Takentogether,thesestepstowardtotalqualitymanagementarepositivesfortheprofession.Aproactivestepmaybeamocktable-topexercise–usingareal,orinventedscenario,andinvolvingthejail’sriskmanagerandotherstakeholders.Thissimulationcanhelpidentifytrainingandpolicyneeds,andcommunicateaclearsenseofpurposeinconductingthework.Usethisasalearningevent,andcritiqueproposed,oractualjailpolicyandprocedures.Thenextstepsareuptoyou!ResourcesProvidedwiththistoolkitare:• Definitions• Linkstopoliciesandprocedures• CorrectiveActionPlanformats• OrganizationofaRCAreport• ResourcesandBibliographyTheresourcesincludelinkstorootcauseanalysesperformedinvariouspublicsafetycontexts,includingthreeforjails/prisons.Notallrootcausereviewsneedtobeasextensiveand/ordonebyanoutsideorganization.Thereadershould

notbediscouragedbythescopeofsomeofthesereviews.Theseresources,alongwiththeworkscitedinthenarrative,provideajailwiththetoolsneededtoconsiderandimplementRCAaspartoftotalqualitymanagement.

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DefinitionsAccountability-BasedManagementAphilosophyguidingagencyoperationsthatidentifiestheperformanceexpectationsoftheorganization,collectsrelevantdata,measurestheorganization’sprogresstowardmeetingthoseexpectations,andwiththeexistenceofaninternalstructure(policyandprocedures)holdsemployeesandsystemsaccountabletoachievetheexpectations.(Fridell,2006)Actionplanning/ActionPlans(CorrectiveActionPlans)Anactionplanistheproductofaneventreviewwhethertheincident’sassessmentisdoneviaaRCAand/orafter-actionreport/critique/debrief.Theactionplanprocessandformat,aspartofthejail’spoliciesandprocedures,mustinclude,ataminimum:

• aprecisestatementofthemattertoberemediated;• clear,measurable,andspecificactionsthatwillbetaken;• identificationoftheproductoroutcomethatwillprovetheworkisaccomplished;• thenameoftheperson(s)assignedtoeachworkobjectives;• theduedatesforeachelement;• howandwhentherecommendations/outcomewillbeimplementedalongwithanyneededstafftraining;and• howtheimpact(positiveornegative)oftheworkwillbeassessed.

Actionplanscanalsobeusedfornon-emergentissuestoaddresschallengesthejailisexperiencing-suchasemployee

recruitmentorretention,influxofinmatesonOpioids,orincreaseinthenumberofinmatesonthementalhealthcaseload.Assuch,sometimestheterm“preventiveactionplan”isusedtodescribeactivities.Theplanmayalsoincludeadiscussionof“lessonslearned”fromthiseventthatcanbeusedtoimproveoperations.Afteractionreport/critique/debrief

Anafter-actionreviewis“...atoolforquicklyassessingwhathappenedduringanactivityandwhetheranylessonsfromitwouldhelpinthefuture.AnAAR(AfterActionReview)issimple,quick,andimmediatelyresponsivetothesituationandthepeopleinvolved.”(U.S.Dept.ofAgriculture,ForestServices)Thisiscontrastedwiththemorein-depthreviewsnotedforRCA.Afteranevent,mostorganizationscompileaminute-by-minutedescriptionofwhathappenedandwhen–andthewhyeithercomeslater,ornotatall.Theutilityofanafter-actionconceptistocollectalltherelevantinformation,documents,logs,videos,statements,reports,andtestimonytoassuretheseareavailableforpost-reviewinvestigation.Acritiquemayalsobedefinedas“...afact-findingexerciseandachancetorelateandrecordpiecesofinformationthatcollectivelyformapictureoftheeventandhowpersonnelresponded...”(U.S.FireAdministration,FEMA)

Jailleadershipdeterminesviapolicywhateventsorincidentswarrantwhatlevelofreview.ThisMonographdoesnotsuggestthatalljaileventswarrantaRCA.Whatisimportantisthatthejaildelineateswhateventtriggersareviewresponse,andthatthosevariousresponseprocessesare

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time-driven,defined–andnotjustlefttochance.AuditAnauditismostoftendiscussedintermsofreviewingfinancialrecordsanddeterminingcompliancewithlawsandprofessionalstandards.Intermsofcorrections,auditingmostoftenrelatestocompliancewithnational,stateorlocalstandards,laws,orothermeasurablebenchmarks.Forexample,asecurityauditprogramcanbeapositiveapproachconsistentwithriskmanagement.(EvaMartony,2013)AnauditmightinformaRCAand/ormightbetheimpetusforapreventiveactionplan.“Best”practicesAnoutcomeofRCAandactionplanningmaybethesearchfor“best”practicesfromotherjailsthat,ifadopted,mightpreventadverseoutcomes.Whilereachingouttothejailcommunityisagoodidea,cautionissuggestedinassessingandadopting“best”practices.Unlessapracticeisresearchand“evidence-based”itmaybebettertoconsideritapromisingidea,oranemergingstrategy.(ElyseClawson,2004)Contributingfactor(s)Whenconductinganincidentreview,theRCAshouldseektoidentifyallfactorswhichmayhaveinfluencedtheevent.Someofthesefactorswillbedirectlycausative,othersnot.Thesefactorsmaybepositiveornegative.Theteamreviewingthefactorsmayassignweightstothefactorsperhapssuchasmajor,intermediateorminor.Forexample,arooffailureatajailmaybedirectlycausedbyaweatherevent,butan

intermediatecontributingfactormaybetheabsenceofafundedpreventivemaintenanceplan,orineffectiverepairs.CriticalincidentAnyeventdefinedbythejail’spoliciesandproceduresasrequiringastructuredanalysisand,ifnecessary,anactionplan.Evidence-Based“Anevidence-basedorganization(EBO)consistentlydemonstratestheabilitytoachieveoutcomesthrougheffectiveproblemsolvinganddecisionmaking.Asthenameimplies,suchanorganizationsimultaneouslyusesevidencetoachieveitsoutcomesandcorroboratesthoseoutcomesthroughmeasurementandexhaustivecommunication.AnEBOusesdatatodrivedecisionsanddevelopinnovativeapproachestodeliveryservices.”(ChristineAmenn,2010)Fact-findingAprocessthatgathersandorganizesbasicinformationabouttheeventunderreview,includingpreparationofalistofalldocuments,logs,videos,statements,relevantpolicies,etc.Thisactivityisinpreparationforanalysis,developmentoffindings,andcreationofactionplans.Fact-findingisgenerallyanintegralpartofRCA,butisinandofitselfnotintendedtobeinvestigatoryorconclusory.FishboneTool(IshikawaDiagram)Adiagramsometimesusedaspartoftheteamexaminationprocessofanadverseincident.(U.S.DepartmentofHealthandHumanServices,CentersforMedicareandMedicaidServices,n.d.)Thetoolprovidesavisualdisplayoftheproblem

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statement,theenvironment,thepeopleinvolved,equipment/supplies,andpoliciesandprocedures.ThismethodwasdevelopedbyaJapaneseengineeringprofessortoimprovequalitymanagementprimarilyinmanufacturing.SometeamsmightfindthevisualapproachhelpfulinRCA.IncidentDebriefingAmechanismforcommunicatinginformationtoagencyemployeeseitherpost-incident,and/oratthecompletionofaRCA.ThepurposeofthedebriefingistoupholdthetransparentnatureofRCA,addressrumors,relievefearscreatedbytheevent,commendstaff,demonstrateleadership,andpointtowardanychangesthatwillbeimplemented.Morbidityandmortalityreviews(M&M)Astandardpracticeinthemedicalprofession,theobjectiveofan“M&M”isto“...analyzeacasewithanadverseoutcometoidentifycontributingfactors.ThisprocessallowsM&Mparticipantstolearnfromthecaseandworktopreventfutureharmtopatients.Therefore,M&Msitsattheintersectionofperformanceimprovement,medicaleducation,andpeerreviewactivities.”(DarleneTad-y,2013)Itisessentialthatthejail’smedicalproviderhaveproceduresinplacetoconductM&Mreviewsforincidentsinvolvingseriousthreats/outcomestoinmates’medicalandmentalhealth.ItislikelyintheconversationaboutRCAthatanM&Mreviewwillprovidecriticalinformation,possiblyofatechnicalnature,toinformthereviewoftheadverseevent.M&Mreviewsexaminenotonlytheindividualpatient,butthesystemsthatwerepartoftheoutcome,

including,forexample,protocolsandresponsivenessofthecorrectionsstaff.ThereisoftendebateaboutwhethertheM&Mdocumentissharedwithjailleadership,orotherwiseavailable.Thisaccessibilitymaybeguidedbythecontractingdocument,orotherlegaldecisions.Insomeinstances,theresultsoftheM&Mmayonlybesharedverbally.ItisessentialforthejailleadertoassurethatanyactionplantoaddressdeficienciesrevealedinanM&Mareaddressedinatimelyandthoroughmanner.NationalIncidentManagementSystem(NIMS)IncidentCommandSystem(ICS)

“NIMSisasystematic,proactiveapproachtoguidedepartmentsandagenciesatalllevelsofgovernment,nongovernmentalorganizations,andtheprivatesectortoworktogetherseamlesslyandmanageincidentsinvolvingallthreatsandhazards–regardlessofthecause,size,locationorcomplexity–inordertoreducelossoflife,propertyandharmtotheenvironment.”(FEMA,2017)ThisMonographwillnotdevotetimetoexploringNIMSICSandencouragesreaderstoreviewthematerialsnotedinthebibliography.ItispossiblethatajailmightbeinvolvedinNIMSdependingthescopeoftheincident(e.g.hurricane,terrorism,community-widedisaster).ThewebsitesincludedinthebibliographyprovidethelinktotheNIMSsupportingguidesandtools,reportingformats,andresources.JailsmayalsosubscribetotheNIMSmailinglist.FEMAalsoprovidestrainingandtechnicalassistance.

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Non-conformity

DuringthecompletionofaRCAidentificationofactions,environmentalissues,orcircumstanceswhichdonotfallwithinpolicy,procedures,and/oracceptedpractice.Mayalsobereferredtoasnon-compliant.QualityAssessmentandQualityImprovement(QA/QI)Termsborrowedfromthemedicalprofession,QA/QIandcontinuousqualityimprovementallseektoassessandimprovehealthcaredelivery.AswithCQI,thisisadatadrivenprocessleadingtobetterpatientoutcomesandasaferjail.Theobjectivesaretodetermineifthereiscompliancewithprocessesandmeasureandanalyzeoutcomes.TherearetwotypesofQIstudies.OutcomeQIStudiesexaminewhetherexpectedoutcomesofpatientcarewereachieved.ProcessQIstudiesexaminetheeffectivenessofthehealthcaredeliveryprocess.Baselinestudiesareacomponentinboth(NationalCommissiononCorrectionalHealthCare,2018)Riskassessment/managementRiskassessmentistheprocessbywhichanorganizationidentifiesandexaminesthepotentialharmorimpactofrealisticallyanticipatedand/orunforeseenevents.Whileitisanuncertainworldforajail,bothinternallyandexternally,aroutineandconsistentprocesstoassessriskisimportant.Theserisksmaybeassociatedwith,forexample:• thephysicalplant(secureperimeter,

roof,HVAC,glazing,doors,locks,parkinglots,road/walkways,physical

plantassessment);(McCampbell,2016)

• humanresources(adequacyofthenumberofemployees,employeescreeningandhiringprocess,pre-serviceandin-servicetraining,internalinvestigationsandemployeemisconductreviews,employeediscipline,worker’scompensation);

• inmatemedical,mentalhealthanddentalcareandpressingchallengessuchasprevalenceofmentalillness,andtheopioidcrisis;

• financialandbudgeting;• legal(laws,administrative

regulations,caselaw,consentjudgments,rules,e.g.PREA);

• policies,procedures,lessonplans,training;and

• inmateprogrammingandservices.(Martin,2008)

• Severeweatherevents(e.g.flood,hurricane,tornado)

Riskassessment/management,routinelyperformed,willassistthejailtoavoidadverseevents–forexample,identifyingtheneedforandinstallingnewlockingmechanismsinhousingunits–topreventinmate/inmatealtercations.Itisaseparate,butintegrallyrelatedmatter,ifthejailnotifiesthefundingauthorityofsuchneeds,butdoesn’treceivefunding.Inthiscase,theassessmentsprovidethedocumentationofefforts.RelatedtoRCA,theabsenceofariskassessment/managementprograminthejailmaybeacontributingfactor.Oftenthejailitselfmayneedtorelyonthefundingorpoliticalauthorities’expertsorinsuranceproviderstoconductthiswork.

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RootCauseAnalysisAtransparent,collaborativeprocess,occurringafterasentinelevent,ortoaddressanemergingoperationalchallenge,designedtogatherdata,thoroughlyanalyzetheevent(sometimeslabeledasdeterminingthe“5Ws”–whowhatwhen,where,why),determinecausation,articulaterecommendations,withtheultimateobjectivesofreducingriskandpreventingfutureoccurrencesofadverseeventsthroughimplementingmeasurableandtime-drivenaction-plans.ThepurposeofaRCAistofindoutwhathappened,whyithappened,anddeterminewhatchangesneedtobemade.(U.S.Dept.ofHeathandHumanServices,CentersforMedicareandMedicaidServices,n.d.)Self-criticalanalysisprivilegeAlegalconceptthatseeksto“...protectself-evaluativematerialsfromdiscoverywhenthepublicinterestinpreservingtheinternalevaluationsoforganizationsoutweighsaplaintiff’srighttotheevidence.Courtsrecognizethatorganizationsmaybelesslikelytoengageinself-policing,andinadditionmaycompilelessreliableinformationwhendoingso,ifplaintiffscanaccesstheresultsoftheseself-analyses.”(Jones,2003)

SentinelEventReviews(SERs)

AsnotedintheIntroduction,asentineleventismostoftendefinedas“...abadoutcomethatnoonewantsrepeatedandthatsignalstheexistenceofunderlyingweaknessesinthesystem.”(U.S.DepartmentofJustice,OfficeofJusticePrograms,NationalInstituteofJustice,2014)“Asentineleventisasignificant,

unexpectednegativeoutcomethatsignalspossibleunderlyingweaknessesinasystemorprocess;islikelytheresultofcompounderrors;andmayprovidekeystopreventingfutureadverseeventsoroutcomes.”(U.S.DepartmentofJustice,NationalInstituteofJustice)Sentineleventsshouldserveasearlywarningsofpendingadverseevents.ThroughanongoinginitiativeoftheU.S.DepartmentofJustice’sNationalInstituteofJustice,thethreefundamentalprinciplesofasentineleventrevieware:• “Non-blaming:Reviewsmustnotbe

framedasahuntforabadactor.Rather,theymustseektounderstandwhymultiple,smallererrorsoccurred;whydecisionsseemedlikethebestdecisionsatthetime;andhowthesystemisstructuredtoallowforsuchmistakes.

• Forward-looking:Reviewsmustbeconductedforthepurposeoflearning,withaneyetowardusinginformationtoimprovepolicyandpractice,andtoreducethelikelihoodoffutureharm.

• All-stakeholders:Reviewsmustincluderepresentativesfromallaspectsofthesystemwhoseactionsand/orfailuretoactcouldhavereasonablycontributedtotheerror.Theymustbewillingandabletoshareallrelevantinformationacrossdisciplinestoinformadeliberative,transparentprocess.”(U.S.Dept.ofJustice,NationalInstituteofJustice)

TotalQualityManagement(TQM)Stemmingfromthepost-WorldWarIIworkofEdwardDeming,TQMseekstolookatissuesatanorganizationlevelandworkstoestablishandthenexamineprocessestoaccomplish,andcorrect

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activitiesleadingtoachieveoftheorganization’smissionandvision,inclusiveofcustomersandstakeholders.Itiscustomer-focused,involvesallemployees,isprocesscentered,integrated,strategicandsystematic,focusesoncontinualimprovement,isdataandfactdriven,groundedinmeaningfulandtimelycommunication.(Quality,n.d.)Inamedicalenvironment,thepurposeofTQMis“...continuousqualityimprovementistoimprovehealthcarebyidentifyingproblems,implementingandmonitoringcorrectiveactionandstudyingitseffectiveness.”(NationalCommissiononCorrectionalHealthCare,2010)

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LinkstoPolicies/Procedures

Theseexamplesareprovidedfortheeducationofthereader,withNOassessmentoftheir

effectiveness,norendorsementbytheauthors.Theseexamplesareavailableonpublicwebsites.Examplesfromhealthandbehavioralhealthsettingsarealsorelevant.Theselinksare

operationalasofthisdate.Iftheynolongerwork,searchonthereporttitleformoreinformation.

StateofIndiana,DepartmentofCorrections,IncidentReporting,MonitoringandMapping(7/1/2013)https://www.in.gov/idoc/files/02-03-114%20Incident%20Monitoring%204-1-19.pdfStateofMichigan,DepartmentofCorrections,CriticalIncidentReporting,(2/6/17)https://www.michigan.gov/documents/corrections/01_05_120_626667_7.pdfStateofOregon,YouthAuthority,IncidentReviews(9/30/16)https://www.oregon.gov/oya/policies/i-e-4.0.pdfCountyofSanBernardino,Dept.ofBehavioralHealth,RootCauseAnalysisPolicy(3/23/09)http://wp.sbcounty.gov/dbh/wp-content/uploads/2016/08/COM0939.pdf

StateofConnecticut,DepartmentofMentalHealthandAddictionServices,CriticalIncidentReportingGuide,September2016https://www.ct.gov/dmhas/lib/dmhas/eqmi/CI-reportingguide2016.pdfKansasJuvenileJusticeAuthority,InternalManagementPolicyandProcedure,CriticalIncidentReporting,https://www.doc.ks.gov/kdoc-policies/juvenile-impp/security-and-control/12-120.pdf/viewMentalHealthCoordinatingCouncil,SampleEmergencyandCriticalIncidentPolicyandProcedure,PsychologicalInjuryManagementGuide2012,http://pimg.mhcc.org.au/media/1469/sample-emergency-critical-incident_policy-and-procedure.pdfNationalCommissiononCorrectionalHealthCare,ProcedureintheEventofanInmateDeath,http://www.ncchc.org/spotlight-on-the-standards-23-3

CauseAnalysis,January11,2008,https://portal.ct.gov/-/media/DDS/DDS_Manual/ID_Root/RootCauseAnalysisPro1.pdf?la=en

UniversityofKansas,WorkGroupforCommunityHealthandDevelopment,CommunityToolBox,Section5.DevelopinganActionPlan,http://ctb.ku.edu/en/table-of-contents/structure/strategic-planning/develop-action-plans/main

WashingtonStateDept.ofCorrections,ReportingandReviewingCriticalIncidents,10/20/14,http://www.doc.wa.gov/information/policies/showFile.aspx?name=400110

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CorrectiveActionFormats/Templates

Therearemanyformatsandtemplatesforcorrectiveactionplans.AreviewoftheInternetidentifiesmanyoptions.Herearesomeideasforyourteamtoconsider.Theformatcanbeassimplisticorasdetailedasrequiredbythejail’spolicyandthenatureoftheevent/incident.Theoperationalpolicy/writtendirectiveshoulddefineeachelement.AswithallcomponentsoftheRCAprocess,thesetemplates

shouldbeassessedaftereachuseandmodifiedtoadapttothejail’sneeds.

Sample#1Issue/Event/Incident:DateofDevelopment:DatesofRevision/Reporting:Item#

Conditiontobeaddressed

(Measurable/objective)Steps Timelines Who Assistance

Needed/Stakeholders OutputMeasure

ofSuccess

1.0 1.1 1.2 1.3 2.0 2.1 3.0

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Sample#2Issue/Event/Incident:DateofDevelopment:DatesofRevision/Reporting:

Conditiontobeaddressed(Measurable/objective)

Stepstocomplete Timeline/bystep Who AssistanceNeeded/Stakeholders

Output MeasureofSuccess

Conditiontobeaddressed

(Measurable/objective)

Stepstocomplete Timeline/bystep Who AssistanceNeeded/Stakeholders

Output MeasureofSuccess

Item#

Item#

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Sample#3Issue/Event/Incident:DateofDevelopment:DatesofRevision/Reporting:

No. Action ResponsibleParty

PriorityH/M/L

Status/Notstarted/Stated/Completed

PlannedFinishDate

ActualFinishDate

Notes

1.0 1.1.1 1.1.2 1.1.3 2.0 2.1.1 2.1.2 3.0

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Sample#4Issue/Event/Incident:DateofDevelopment:DatesofRevision/Reporting:

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OrganizationofRCAsReports-FormatsandTemplates

TherearemanyformatsandtemplatestoorganizeRCAs.AreviewoftheInternetidentifiesmanyoptions.Herearesomeideasforyourteamtoconsider.Theformatcanbeassimplisticorasdetailedasrequiredbythejail’spolicyandthenatureoftheevent/incident.Theoperationalpolicy/writtendirectiveshould

defineeachelement.AswithallpartoftheRCAprocess,thesetemplatesshouldbeassessedaftereachuseandmodifiedtoadapttothejail’sneeds.ThereareseveralRCAreportsreferencedinthisdocumentthatprovideadditionalideas.

Sample–TableofContentsofanRCAReport(Suggestionsonly,notalltopicsmayberelevanttothematterunderreview) Introduction Purpose

ScopeandObjectivesRCAteamleaderandmembers

ExecutiveSummary BackgroundReportMethodology Datacollectionandanalysis

SummaryofIncident/EventNarrative ResponseAnalysisofIncident/Event Chronologyofevents

Findings/RootCauses(Aseachtopicisapplicable) Administrativeissues(e.g.budget) Classification Commandandcontrol Communication Environment Equipment Externalenvironment InformationTechnology Inmatematters Leadership Policies,procedures,writtendirectives,andpractice Inmateclassification AuditsandInspections Employeehiringandbackgroundinvestigations Postevent

Staffing Atthetimeoftheincident/event

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Fatigueandscheduling Supervision Training–toincluderetainingofstaffabouthowRCAsworkandtheirrole Conclusions,LessonsLearned Recommendations Appendices

Listofdocumentsreviewed Listofinterviews Listofteammembers Photographs/videos Otheritemsreviewed

OptionsforOrganizingInformationOption1–ChronologyofEventsDiagram Reviewtheflowofevents:

Adverseoutcome

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Option2-TheWhysCaliforniaHealthCare

Considerthefactorsthatresultedinthenegativeevent(orthematterunderconsideration).Brainstormthe“why”ofeach.

Whyisthat?

Whyisthat?

Whyisthat?

Whyisthat?

Whyisthat?

FactorBeingConsidered:

1.

2.

3.

4.

5.

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Option3–FishboneDiagram(Ishikawa)Thisoptionallowsthereviewerstogroupvariouscausesbycategoriesdesignedbythereviewers–forexample,people,process,equipment,materials,environment,management,etc.)Theuseofthismethodrequiresassuringbackgroundisgathered,andthatemployeesusingthetechniqueareallproceedingwiththesameunderstanding.Internetresearchwillprovidemultiplevendorsandresourcesforthisstrategy.TheInternetprovidesmoreexamplesofthistemplate.

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ResourcesandBibliography

Note:thelinkstothesematerialswereworkingasofthedateofpublication.Ifthelinknolonger

works,searchthetitleofthedocument.

ContinuousQualityImprovement/TotalQualityManagement/Evidence-BasedPracticeFranklin,Godfrey,JohnS.Platt,WalterJ.Wheatley,PaulJ.Bohac,“CorrectionsandTQM–DotheyMix?”JournalofCorrectionalEducation,Vol.48,Issue1,March1997,p.31.Gleicher,Lily,“ImplementationScienceinCriminalJustice:HowImplementationofEvidence-basedProgramsandPracticesAffectsOutcomes”,Evidence-InformedPractices,October20,2017,http://www.icjia.state.il.us/articles/implementation-science-in-criminal-justice-how-implementation-of-evidence-based-programs-and-practices-affects-outcomesHolloway,John,“LegalOptimism:RestoringTrustintheCriminalJusticeSystemThroughProceduralJustice,PositivePsychologyandJustCultureEventReviews”,MasterofAppliedPositivePsychology,UniversityofPennsylvania,October10,2018https://repository.upenn.edu/cgi/viewcontent.cgi?article=1155&context=mapp_capstoneHouston,James,TotalQualityCorrections,PolicinginCentralandEasternEurope:DilemmasforContemporaryCriminalJustice,December2004,https://www.ncjrs.gov/pdffiles1/nij/Mesko/207983.pdfMatthews,Brandon,D.M.,“WeNeedtoEvolveCorrectionalQualityManagementintheEraofEvidence-BasedPractice”,October16,2017,https://www.linkedin.com/pulse/we-need-evolve-correctional-quality-management-era-mathews-d-m-Orchowsky,Stan,AnIntroductiontoEvidence-BasedPractices,JusticeResearchandStatisticsAssociation,April2014,http://www.jrsa.org/pubs/reports/ebp_briefing_paper_april2014.pdfRiley,William,Ph.D.,“ReviewandAnalysisofQualityImprovement(QI)TechniquesinPoliceDepartments”,PreparedforRobertWoodJohnsonFoundation,StateHealthDepartmentConference,

February7,2007,http://www.phaboard.org/wp-content/uploads/ReviewandAnalysisofQITechniquesinPoliceDepartments.pdfRudes,DanielleS,JillViglione,CortneyM.Porter,“UsingQualityImprovementModelsinCorrectionalOrganizations”,GeorgeMasonUniversity,CenterforAdvancingCorrectionalExcellence,FederalProbation,Volume77,Number2,September2013,http://www.uscourts.gov/sites/default/files/77_2_12_0.pdfYoung,Cheryl,DanPacholke,DevonSchrum,PhilipYoung,KeepingPrisonsSafe:TransformingtheCorrectionsWorkplace,SustainabilityinPrisonsProject,PrisonsDivision,WashingtonDepartmentofCorrections,2014.CorrectiveActionPlansFEMA,FEMAIncidentActionPlanningGuide,January2012,https://www.fema.gov/media-library-data/20130726-1822-25045-1815/incident_action_planning_guide_1_26_2012.pdfCriticalIncidentReviews/RootCauseAnalysesBraziel,Rick,FrankStaub,GeorgeWatsonandRodHoops,BringingCalmtoChaos,AcriticalincidentreviewoftheSanBernardinopublicsafetyresponsetotheDecember2,2105,terroristshootingincidentattheInlandRegionalCenter,ThePoliceFoundation,U.S.Dept.ofJustice,CommunityOrientedPolicingServices,2016,https://www.justice.gov/usao-cdca/file/891996/downloadBraziel,Rick,DevonBell,GeorgeWatson,APoliceFoundationCriticalIncidentReviewoftheStocktonPoliceResponsetotheBankoftheWestRobberyandHostage-Taking,ThePoliceFoundation,https://www.policefoundation.org/wp-content/uploads/2015/08/A-Heist-Gone-Bad-Critical-Incident-Review.pdfBraziel,Rick,Melekian,Bernard,,SueRahr,JeffRojek,JimSprecht,TravisTaniguchi,MaryDeStefano,JimBueermann,PoliceUnderAttack:SouthernCaliforniaLawEnforcementResponsetotheAttacksbyChristopherDorner,ThePoliceFoundationhttps://www.policefoundation.org/wp-content/uploads/2015/07/Police-Under-Attack.pdf

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Herrera,ChabeliandAmySherman,“OfficermishandledresponsetoFortLauderdaleAirportshooting,repotsays,leadingtochaos”,June5,2017,http://www.miamiherald.com/news/business/article154497524.htmlJennings,JuneW.,CPA,OfficeoftheStateInspectorGeneralReporttoGovernorTerenceR.McAuliffeInvestigationofCriticalIncidentHamptonRoadsRegionalJail,April2016,https://www.osig.virginia.gov/media/governorvirginiagov/office-of-the-state-inspector-general/pdf/2016-bhds-002-hrrj-death-final-sig-approved.pdfMarjoryStonemanDouglasPublicSafetyCommission,MarjoryStonemanDouglasHighSchoolPublicSafetyCommission,InitialReportSubmittedtotheGovernor;SpeakeroftheHouseofRepresentativesandSenatePresident,January2,2019http://www.fdle.state.fl.us/MSDHS/CommissionReport.pdfMastroianni,GeorgeR.,LookingBack:UnderstandingAbuGhraib,Parameters43(2)Summer2013,https://ssi.armywarcollege.edu/pubs/parameters/issues/Summer_2013/6_Mastroianni_Article.pdfStaub,Frank,JenniferZeunik,MariaValdovinos,MichellePhillips,JoyceIwashita,RogerWerholz,RogerMay,PreliminaryReport:IndependentReviewofSecurityIssuesattheJamesT.VaughnCorrectionalCenter,PoliceFoundation,February14,2017,http://governor.delaware.gov/wp-content/uploads/sites/24/2017/06/Independent-Review-Initial-Report-June-2-2017.pdfStraub,Frank,BrettCowell,JenniferZeunik,BenGorban,ManagingtheResponsetoaMobileMassShooting:ACriticalIncidentReviewoftheKalamazoo,Michigan,PublicSafetyResponsetotheFebruary20,2016,MassShootingIncident,April2017,ThePoliceFoundationhttps://www.policefoundation.org/wp-content/uploads/2017/05/PF_Managing-the-Response-to-a-Mobile-Mass-Shooting_5.10.17.pdfStraub,Frank,Hassanden,JeffreyBrown,BenGorban,RodneyMonroe,JenniferZeunik,MaintainingFirstAmendmentRightsandPublicSafetyinNorthMinneapolis,AnAfter-ActionAssessmentofthePoliceResponsetoProtest,

Demonstrations,andOccupationoftheMinneapolisPoliceDepartment’sFourthPrecinct,U.S.Dept.ofJustice,OfficeofCommunityOrientedPolicingServicesCriticalResponseInitiative,2017,https://www.policefoundation.org/wp-content/uploads/2017/03/Maintaining-First-Amendment-Rights-and-Public-Safety-in-North-Minneapolis.pdfGeneralResourcesBarsalou,MatthewA.,RootCauseAnalysis,AStep-by-StepGuidetoUsingtheRightToolattheRighttime,CRSPress,2015.Connors,RogerandTomSmith,HowDidthatHappen?HoldingPeopleAccountableforResultsinthePositive,PrincipledWay,Portfolio/Penguin,2009.Doyle,JamesM.,“NIJ’sSentinelEventsInitiative:LookingBacktoLookForward,”U.S.DepartmentofJustice,NationalInstituteofJustice,NIJJournal/Issue273,March2014https://www.ncjrs.gov/pdffiles1/nij/244145.pdfDoyle,JamesM.,“NIJ’sSentinelEventsInitiative:ReducingErrorsintheCriminalJusticeSystem”,CorrectionsToday,January/February2015https://www.ncjrs.gov/pdffiles1/nij/248576.pdfNationalCommissiononCorrectionalHealthCare,StandardsforHealthServicesinJails,NCCHC,2018Reason,James,ManagingtheRisksofOrganizationalAccidents,Ashgate,1997.Tad-y,Darlene,MDandHeidiWald,MD,SystemsandQualityM&MToolkit,DepartmentofMedicine,UniversityofColorado,2013,http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/FacultyStaffRes/ClinicRes/Documents/DOM%20MandM%20Toolkit%204_11_13.pdfU.S.Dept.ofJustice,CommunityRelationsServicesToolkitforPolicies,PoliceCriticalIncidentChecklist,https://www.justice.gov/crs/file/836421/downloadU.S.DepartmentofJustice,NationalInstituteofJustice,MendingJustice:SentinelEventReviews,September2014,

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https://www.ncjrs.gov/pdffiles1/nij/247141.pdfU.S.DepartmentofJustice,NationalInstituteofJustice,TheSentinelEventInitiative:ProceedingsfromanExpertRoundtable,May21-22,2013,Alexandria,Virginiahttps://www.ncjrs.gov/pdffiles1/nij/243586.pdfU.S.DepartmentofJustice,NationalInstituteofJustice,NIJStrategicResearchandImplementationPlan:SentinelEventsInitiative2017-2012,https://www.ncjrs.gov/pdffiles1/nij/250472.pdfJail-RelatedCoreCompetenciesMcCampbell,SusanW.,“CoreCompetenciesandJailLeadership:Decision-Making,”AmericanJails,VolumeXXIX,Number3,July/August2015,page45,http://www.cipp.org/uploads/3/7/5/7/37578255/13_sound_decisions_no_ads.pdfMcCampbell,SusanW.,“CoreCompetenciesandJailLeadership:OrganizationalAccountability:TheRealBreakfastofChampions,”AmericanJails,July/August2016,page35,http://www.cipp.org/uploads/3/7/5/7/37578255/2_organizational_accountability.pdfMcCampbell,SusanW.andMalikMuhammad,“CoreCompetenciesandJailLeadership:CriticalThinking:SolvingtheRealProblem,”AmericanJails,May/June2017,page45,http://www.cipp.org/uploads/3/7/5/7/37578255/1_critical_thinking.pdfMcCampbell,SusanW.,“JumpStartYourJail’sLeadershipDevelopment”,March2019,CIPP,http://www.cipp.org/uploads/3/7/5/7/37578255/cipp_jump_start_leadership_development__3_28_19.pdfLegalIssuesDoyle,JamesM.,LearningfromErrorinAmericanCriminalJustice,TheJournalofCriminalLawandCriminology,NorthwesternUniversity,SchoolofLaw,Vol.100,No.1,2010https://scholarlycommons.law.northwestern.edu/cgi/viewcontent.cgi?referer=https://r.search.yahoo.com/_ylt=AwrCwPSO0I9brygAWQ8PxQt.;_ylu=X3oDMTByOHZyb21tBGNvbG8DYmYxBHBvcwMxBHZ0aWQDBHNlYwNzcg--/RV=2/RE=1536180495/RO=10/RU=http%3a%2f

%2fscholarlycommons.law.northwestern.edu%2fcgi%2fviewcontent.cgi%3farticle%3d7346%26context%3djclc/RK=2/RS=qcc.bqDJPtRYAa3gGAkBFXBkKg8-&httpsredir=1&article=7346&context=jclcHollway,John,ASystemsApproachtoErrorReductioninCriminalJustice,UniversityofPennsylvaniaLawSchool,February2014https://scholarship.law.upenn.edu/cgi/viewcontent.cgi?referer=https://r.search.yahoo.com/_ylt=A0geKVkM0o9b3QwApp8PxQt.;_ylu=X3oDMTByOHZyb21tBGNvbG8DYmYxBHBvcwMxBHZ0aWQDBHNlYwNzcg--/RV=2/RE=1536180877/RO=10/RU=http%3a%2f%2fscholarship.law.upenn.edu%2fcgi%2fviewcontent.cgi%3farticle%3d1975%26context%3dfaculty_scholarship/RK=2/RS=f5CjtkcvWJfmngUGt_.XKAELnOc-&httpsredir=1&article=1975&context=faculty_scholarshipHollway,JohnF.,ReviewingPoliceUseofForcethroughRootCauseAnalysis,TheRegulatoryReview,February15,2017,https://www.theregreview.org/2017/02/15/hollway-reviewing-police-use-force-root-cause-analysis/JoshJones,BehindtheShield?LawEnforcementAgenciesandtheSelf-CriticalAnalysisPrivilege,WashingtonandLeeLawReview,Volume60,Issue4,Article16,9-1/2003,https://scholarlycommons.law.wlu.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1261&context=wlulrUniversityofPennsylvania,QuattroneCenterforFairAdministrationofJustice,UsingRootCauseAnalysistoInstillaCultureofSelf-Improvement:ProgramReplicationMaterialsInnovationsinCriminalJusticeSummitIII,April20-21,2015,https://www.law.upenn.edu/live/files/4291-impact-report-root-cause-analysisRiskManagementinJailsMartin,MarkD.andClaireLeeReiss,ManagingRiskinJails,U.S.DepartmentofJustice,NationalInstituteofCorrections,April2008,https://www.hsdl.org/?view&did=719589Martin,MarkD.,JailStandardsandInspectionPrograms:ResourceandImplementationGuide,U.S.DepartmentofJustice,NationalInstituteofCorrections,April2007,

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https://www.prearesourcecenter.org/sites/default/files/library/jailstandandsandinspectionprogramsresourceandimplementationguide.pdfMartin,MarkD.,andPaulKatsampes,Sheriff’sGuidetoEffectiveJailOperations,U.S.DepartmentofJustice,NationalInstituteofCorrections,January2007,https://s3.amazonaws.com/static.nicic.gov/Library/021925.pdfMartony,Eva,LarryReid,CornellSmith,CeciliaReynolds,JamesUpchurch,CarrollParrish,RayHobbs,JoanPalmateerandAnnieHarvey,TheSecurityAuditProgram:AHow-ToGuideandModelInstrumentforAdaptiontoLocalStandards,Policies,andProcedures,U.S.DepartmentofJustice,NationalInstituteofCorrections,September2013.Pope,LeahandAyeshaDelaney-Brumsey,CreatingaCultureofSafety,SentinelEventReviewsforSuicideandSelf-HarminCorrectionalFacilities,December2016,VeraInstituteofJusticehttps://www.vera.org/publication_downloads/culture-of-safety-sentinel-event-suicide-self-harm-correctional-facilities/culture-of-safety.pdf

Reiss,ClaireLeeandMarkD.Martin,ManagingRiskinJails,RiskManagementMagazine,RickandInsurancesManagementSociety,Inc.,http://cf.rims.org/Magazine/PrintTemplate.cfm?AID=3855Sabbatine,Ray,RiskManagementinjails:howtoreducethepotentialofnegativeoutcomes,AmericanCorrectionalAssociation,2003,https://www.thefreelibrary.com/Risk+management+in+jails%3a+how+to+reduce+the+potential+of+negative...-a0123670504Schwartz,Jeffrey,andCynthiaBarry,AGuidetoPreparingforandRespondingtoJailEmergencies:Self-AuditChecklists,ResourceMaterials,CaseStudies,U.S.DepartmentofJustice,NationalInstituteofCorrections,October2009,https://info.nicic.gov/nicrp/system/files/023494.pdf

Schwartz,Jeffrey,andCynthiaBarry,AGuidetoPreparingforandRespondingtoJailEmergencies:Self-AuditChecklists,ResourceMaterials,CaseStudies,U.S.DepartmentofJustice,NationalInstituteofCorrections,October2009,http://static.nicic.gov/Library/023494.pdfZarnescu,Diana,RiskManagementexperts:Aprisonpractice,http://www.performancemagazine.org/risk-management-experts-a-prison-practice/RootCauseAnalysesBRGGlobalStandards,UnderstandingRootCauseAnalysis,6/1/2012,https://images.template.net/wp-content/uploads/2015/10/17170204/Fishbone-Template-for-Root-Cause-Analysis.pdfCMS.gov,QAPI,GuidanceforPerformingRootCauseAnalysis(RCA)withPerformanceImprovementProjects,https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/guidanceforrca.pdfCMS.gov,QAPI,HowtoUsetheFishboneToolforRootCauseAnalysis,https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdfFEMA,NationalIncidentManagementSystemIncidentCommandSystem,September2010https://www.fema.gov/media-library-data/20130726-1922-25045-7047/ics_forms_12_7_10.pdfHolloway,John,CalvinLeeandSeanSmoot,“RootCauseAnalysis:ATooltoPromoteOfficeSafetyandReduceOfficerInvolvedShootingsOverTime”,62Vill.L.Rev.883(2017)https://scholarship.law.upenn.edu/cgi/viewcontent.cgi?article=2960&context=faculty_scholarshipHowandWhytoConductaCriticalIncidentReview,FireFightingNation,2011,http://www.firefighternation.com/articles/2011/07/how-why-to-conduct-an-incident-debriefing.html

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Gatlin,J.L.,et.al.,ImprovingSafetyThroughRootCauseAnalysis,U.S.Dept.ofEnergy,1992https://www.osti.gov/servlets/purl/5244550Hayes,LindsayM.,Chapter16ReducingInmateSuicidesThroughtheMortalityReviewProcess,https://www.prisonlegalnews.org/media/publications/reducing_inmate_suicides_through_the_mortality_review_process_ch16_lindsay_hayes.pdfLatino,RobertJ.,TheTop10ElementsofaRootCauseAnalysisEffort,ReliabilityCenter,Inc.,https://reliability.com/industry/articles/article75.pdfRitter,Nancy,TestingaConceptandBeyond:CantheCriminalJusticeSystemAdoptaNonblamingPractice?U.S.DepartmentofJustice,NationalInstituteofJustice,NIJJournal/IssueNo.276,December2015,https://www.ncjrs.gov/pdffiles1/nij/249220.pdfRooney,JamesJ.andLeeN.VandenNeuvel,RootCauseAnalysisforBeginners,QualityProgress,July2004,https://www.env.nm.gov/aqb/Proposed_Regs/Part_7_Excess_Emissions/NMED_Exhibit_18-Root_Cause_Analysis_for_Beginners.pdf

RootCauseAnalysisHandbook,WSRC-IM-91-3,DepartmentofEnergy,1991(andearlierversions).https://www.osti.gov/servlets/purl/10153510WashingtonStateDepartmentofEnterpriseServices,RootCauseAnalysis,http://www.des.wa.gov/services/risk-management/about-risk-management/enterprise-risk-management/root-cause-analysisU.S.DepartmentofVeteransAffairs,RootCauseAnalysisTools,VANationalCenterforPatientSafety,October20,2016https://www.patientsafety.va.gov/docs/joe/2014%20RCA%20Tools%20FINAL%20Formatted%20REV10%202016.pdf

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WorksCitedCaliforniaCorrectionalHealthCareServices.(April2013).RCARootCauseAnalysisToolKit.CaliforniaCorrectionalHealthCareServices.(n.d.).RCARootCauseAnalysisToolKit.Retrievedfromhttps://cchcs.ca.gov/wp-content/uploads/sites/60/PP/IMSPP-v03-ch07.2.pdfChristineAmenn,J.L.-C.(2010).Evidence-BasedPracticeSkillsAssessmentforCriminalJusticeOrganizations,Version1.0.Washiongton,DC:U.S.Dept.ofJustice,NationalInstituteofCorrections.DarleneTad-y,M.H.(2013).SystemsandQualityM&MToolkit.(U.o.DepartmentofMedicine,Producer,&http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/FacultyStaffRes/ClinicRes/Documents/DOM%20MandM%20Toolkit%204_11_13.pdfDoyle,J.M.(2010).LeaningfromErrorinAmericanCriminalJustice.TheJournalofCriminalLawandCriminology,100(1),110.Doyle,J.M.(2010).LearningfromErrorinAmericanCriminalJustice.TheJournalofCriminalLawandCriminology,100(1),114.Doyle,J.M.(2010).LearningfromErrorinAmericanCriminalJustice.TheJournalofCriminalLawandCriminology,100(1),125.Doyle,J.M.(2014,March).NIJ'sSentinelEventsInitiative:LookingBacktoLookForward.NIJJournal(273),p.1.ElyseClawson,L.J.(2004).ImplementingEvidence-BasedPracticeinCommunityCorrections:ThePrinciplesofEffectiveIntervention.U.S.DepartmentofJustice,NationalInstituteofCorrections.https://s3.amazonaws.com/static.nicic.gov/Library/019342.pdfEvaMartony,L.R.(2013).TheSecurityAuditProgram:AHow-ToGuideandModelInstrumentforAdaptiontoLocalStandards,PoliciesandProcedures.U.S.Dept.ofJustice,NationalInstituteofJustice.

FEMA.(2010).NationalIncidentManagementSystem(NIMS)IncidentCommandSystem(ICS)FormsBooklet(Vols.https://www.fema.gov/media-library-data/20130726-1922-25045-7047/ics_forms_12_7_10.pdf).Washington,D.C.:FEMAFEMA.(2017).(FEMA,Producer)Retrievedfromhttps://www.fema.gov/national-incident-management-systemFridell,S.O.(2006).ImplementinganAgency-LevelPerformanceMeasurementSystem:AGuideforLawEnforcementExecutive.Washington,DC:PoliceExecutiveResearchForum.Hope,L.(2017,April15).VideosreleasedinexcessiveforcecasesatCookCountyJail.RetrievedSeptember14,2017,fromabc7chicago.comJones,J.(2003).BehindtheShield?LawEnforcementAgenciesandtheSelf-CriticalAnlaysisPrivilege.WasingtonandLeeLawReview,60,1609.Jones,J.(2003).BehindtheShield?LawEnforcementAgenciesandtheSelf-CriticalAnalysisPrivilege.WashingtonandLeeLawReview,60(4,Article16).Kotter,J.P.(1996).LeadingChange.Boston,Ma:HarvardBusinessSchoolPress.Martin,M.D.(2008).ManagingRiskinJail(http://static.nicic.gov/Library/022666.pdfed.).Washington,DC:U.S.DepartmentofJustice,NationalInstituteofCorrections.McCampbell,S.W.(2016,July/August).CoreCompetenciesforJailLeaders:OrganizatiionalAccountability.AmericanJails.McCampbell,S.W.(2016,January/February).CoreCompetency:Comprehend,ObtainandManageFiscalResources.AmericanJails.McCampbell,S.W.(2016,July/August).OrganizationalAccountability:TheRealBreakfastofChamptions.AmericanJails.McCampbell,S.W.(2016,September/October).ThePhysicalPlanandInfrastructure:TheJailLeader'sResponsibilities.AmericanJails.

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McCampbell,S.W.(2016,Sept/Oct).ThePhysicalPlantandInfrastructure:TheJailLeader'sResponsibility.AmericanJails.McCampbell,S.W.(2019,Jan/Feb).CoreCompetenciesforJailLeaders:ReduceJail-RelatedLiabilities.AmericanJails.NationalCommissiononCorrectionalHealthCare.(2010).ContinuousQualityImprovement.Retrievedfromhttp://www.ncchc.org/spotlight-on-the-standards-24-1NationalTransportationSafetyBoard.(n.d.).TheInvestigativeProcess.Retrievedfromhttps://www.ntsb.gov/investigations/process/Pages/default.aspxQuality,A.S.(n.d.).WahtisTotalQualityManagement(TQM)?Retrievedfromhttp://asq.org:http://asq.org/learn-about-quality/total-quality-management/overview/overview.htmlReason,J.(1997).ManagingtheRisksofOrganizationalAccidents.UK:AshgatePublishingLtmd.Ritter,N.(2015,December).TestingaConceptandBeyond:CantheCriminalJusticeSystemAdoptaNonblamingPractice?NIJJournal,276.Thompson,J.(2014,September).TheBlameGame.MendingJustice:SentinelEventReviews,36.U.S.DepartmentofHealthandHumanServices,CentersforMedicareandMedicaidServices.(n.d.).HowtoUsetheFishboneToolforRootCauseAnalysis.Retrievedfromhttps://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdfU.S.DepartmentofHomelandSecurity,U.S.FireAdministration;NationalFireDataCenter,FederalEmergencyManagementCenter.(2008).SpecialReport:TheAFTER-ACTIONCRITIQUE:TrainingThroughLessonsLearned(Vols.USFA-TR-159/April2008).(J.Ockershausen,Ed.)FederalEmergencyManagementAgency(FEMA).U.S.DepartmentofJustice,NationalInstituteofJustice.(n.d.).NIJStrategicResearchandImplementationPlan:SentinelEventsInitiative2017-

2021.NationalInstituteofJustice.U.S.DepartmentofJustice.U.S.DepartmentofJustice,OfficeofJusticePrograms,NationalInstituteofJustice.(2014).MendingJustice:SentinelEventReviews.https://www.ncjrs.gov/pdffiles1/nij/247141.pdf.U.S.Dept.ofAgriculture,ForestServices.(n.d.).AfterActionReviews.https://www.fs.usda.gov/Internet/FSE_DOCUMENTS/stelprdb5394559.pdf.U.S.Dept.ofHeathandHumanServices,CentersforMedicareandMedicaidServices.(n.d.).GuidanceforPerformingRootCauseAnalysis(RCA)withPerformanceImprovementProjects(PIP).Retrievedfromhttps://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/guidanceforrca.pdfU.S.Dept.ofJustice,NationalInstituteofJustice.(n.d.).NIJStrategicResearchandImplementatonPlan:SentinelEventsInitiative2017-2021.NationalInstituteofJustice,U.S.DepartmentofJustice.U.S.FireAdministration,FEMA.(n.d.).SpecialReport:TheAfter-ActionCritique:TrainingThroughLessonsLearned.FEMA.https://www.usfa.fema.gov/downloads/pdf/publications/tr_159.pdf.WashingtonStateDepartmentofEnterpriseServices.(n.d.).RootCauseAnalysis.Retrievedfromhttp://www.des.wa.gov/services/risk-management/about-risk-management/enterprise-risk-management/root-cause-analysisWashingtonState,D.o.(n.d.).Retrievedfromhttps://des.wa.gov/services/risk-management/about-risk-management/enterprise-risk-management/root-cause-analysisZarnescu,D.(2017).RiskManagementExperts:APrisonPractice.Retrieved2017,fromPerformanceManazine:http://store.kpiinstitute.org/scheduled-courses

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AbouttheAuthors:SusanW.McCampbell,CJMisPresidentoftheCenterforInnovativePublicPolicies,Inc.,(CIPP)andMcCampbellandAssociates,Inc.CIPPhasledprojectsofrelevancetothejusticesystem:jailrecruitment,retentionandleadershipdevelopment;curriculumtoeffectivelymanageamulti-generationalworkforceincorrections;resourceguidefornewlyappointedwardens,technicalassistancetostateandlocalcorrectionalagencieswithPREA;andthecurriculumfortheNationalSheriffs’Institute.SheteachesintheNationalJailLeadershipCommandAcademy.McCampbellcurrentlyservesasaFederalCourtMonitorforthejailsystemsinMiami-DadeCounty,Florida,OrleansParish,LouisianaandLosAngelesCounty.Ms.McCampbellalsoservedastheDirector,DepartmentofCorrections,BrowardCounty,Florida,Sheriff’sOfficeforfouryearsandservedasChiefDeputy/ActingSheriffforsix(6)monthsfollowingthedeathoftheSheriff.susanmccampbell@cipp.orgMaryE.Earley,CJM,Captain,DouglasCountyDepartmentofCorrections,Nebraska,beganhercareerinCorrectionsin1989asacorrectionalofficerwiththeNebraskaDepartmentofCorrections.Sheworkedinavarietyofpositionsincludingcustody,inmatediscipline,housing,segregation,stafftrainingacademyinstructorandaccreditationmanager.In2007shejoinedtheDouglasCountyCorrectionsteamasaccreditationmanager.DouglasCountybecamethefirstandremainstheonlyaccreditedjailinNebraska.Since2008,shehasservedtheCountyasCaptainwhereshesupervisessupportservices,safetyandcompliance.CaptainEarleyholdsaMastersofPublicAdministration,isaCertifiedJailManager,CertifiedCorrectionalHealthProfessional,AmericanCorrectionalAssociationAuditorandChairperson,MasterInstructorinEmergencyPreparedness,NationalJailLeadershipCommandAcademygraduateandmentor,andhasco-authorednumerouspublicationsaboutsexuallytransmittedinfectionsinalargeurbanjailsetting.mary.earley@douglascounty-ne.gov


4D Reporting the Root Cause Embedding Root Cause Analysis

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