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RCA, other sensitive data kept confidential
The Joint Commission (TJC) states that this information received or developed during the accreditation process will be kept confidential:
The Official Accreditation Decision Report, unless its submission is required by a government agency; is required by organizations with which TJC performs coordinating surveys; or is requested by an accrediting body with which TJC has a formal agreement;
information learned from the organization before, during, or following the accreditation survey, which is used to determine compliance with specific accreditation standards;
an organization's root cause analysis prepared in response to a sentinel event or in response to other circumstances specified by TJC;
all other materials that may contribute to the accreditation decision (for example, medical records, surveyor notes);
written staff analyses and Accreditation Committee minutes and agenda materials;
the algorithms used in the Priority Focus Process;
the Priority Focus Process information used in an organization's survey, other than that provided to the organization's staff prior to survey;
an organization's self-assessment and related Plan(s) of Action;
the identity of any individual who files a complaint about an accredited organization, except when the complaint is shared by TJC with a governmental entity, an organization with which TJC performs coordinated surveys, or accrediting organizations with which TJC has formal complaint-sharing agreements and the receiving organization has agreed to maintain the confidentiality of the complainant. In instances in which the receiving organization cannot assure the confidentiality of the complainant, any complainant-identifying information shall be redacted by TJC prior to sharing.
For more information on what information can be released by TJC, go to http://www.jointcommission.org/AboutUs/Fact_Sheets/08_pip.htm.