Corrective actions and root cause analysis that work

Why this matters

Credible accreditation depends on consistent methods, clear decisions, and evidence that stands up to independent review. This publication translates essential expectations into practical steps so teams can prepare, communicate, and operate with confidence.

Key requirements and expectations

• Separate evaluation from decision to protect impartiality.
• Document roles, responsibilities, and oversight mechanisms.
• Use risk-based controls to prevent bias or errors.
• Record evidence of review, approval, and follow-up.
• Root cause must be demonstrated with evidence.
• Actions should address system failures, not symptoms.
• Effectiveness checks are mandatory.

Evidence and records to prepare

• Policies and committee terms of reference.
• Minutes from governance or impartiality meetings.
• Risk registers and mitigation actions.
• Corrective action records when issues are found.
• Corrective action logs with verification of effectiveness.

Common pitfalls to avoid

• Undocumented decision-making or informal approvals.
• Conflicts not disclosed or not managed to completion.
• Governance roles that are unclear or overlapping.
• Lack of evidence that actions were implemented.
• Closing actions without verifying effectiveness.

Practical checklist

• Confirm governance roles and independence boundaries.
• Document conflict disclosure and recusal steps.
• Maintain an auditable decision trail.
• Verify corrective actions are closed effectively.
• Define effectiveness criteria before closing actions.

Related resources

• Governance Hub
• Impartiality Policy
• Conflicts of Interest
• Complaints & Appeals