Using a Root Cause Analysis for Remediation

Thomas Fox - Compliance Evangelist
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Thomas Fox - Compliance Evangelist

 

The 2023 ECCP re-emphasized the need for both performing a root cause analysis but equally importantly using it to remediate your compliance program. It stated, “a hallmark of a compliance program that is working effectively in practice is the extent to which a company is able to conduct a thoughtful root cause analysis of misconduct and timely and appropriately remediate to address the root causes.”

It went on to state, what additional steps the company has taken “that demonstrate recognition of the seriousness of the misconduct, acceptance of responsibility for it, and the implementation of measures to reduce the risk of repetition of such misconduct, including measures to identify future risk”).” The following questions were then posed:

Root Cause Analysis—What is the company’s root cause analysis of the misconduct at issue? Were any systemic issues identified? Who in the company was involved in making the analysis?

Prior Weaknesses—What controls failed? If policies or procedures should have prohibited the misconduct, were they effectively implemented, and have functions that had ownership of these policies and procedures been held accountable?

You should begin with the question of who should perform the remediation; should it be an investigator or an investigative team which were a part of the root cause analysis? Jonathan Marks, believes the key is both “independence and objectivity.” It may be that an investigator or investigative team is a subject matter expert and “therefore more qualified to get that particular recourse”. Yet to perform the remediation, the key is to integrate the information developed from the root cause analysis into the solution.

 

Marks further noted that the company may also have deficiencies in internal controls. More importantly, the failure to remediate gaps in internal controls “provides the opportunity for additional errors or misconduct to occur, and thus could damage the company’s credibility with regulators” by allowing the same or similar conduct to reoccur. Finally, with both the 2023 ECCP and FCPA Corporate Enforcement Policy, the DOJ has added its voice to prior SEC statements that regulators “will focus on what steps the company took upon learning of the misconduct, whether the company immediately stopped the misconduct, and what new and more effective internal controls or procedures the company has adopted or plans to adopt to prevent a recurrence.”

As required under the 2023 ECCP, from the regulatory perspective, the critical element is how did you use the information you developed in the root cause analysis? Every time you see a problem as a CCO, you should perform a root cause analysis. Was something approved or not approved before the untoward event happened? Was any harm was done? Why or why not? Why did that system fail? Was it because the person who is doing the approval was too busy? Was it because people didn’t understand? It is in answering these and other questions which have been developed through a root cause analysis that you can bring real value and real solutions to your compliance programs.

The key is that after you have identified the causes of problems, consider the solutions that can be implemented by developing a logical approach, using data that already exists in the organization. Identify current and future needs for organizational improvement. Your solution should be a repeatable, step-by-step processes, in which one process can confirm the results of another. Focusing on the corrective measures of root causes is more effective than simply treating the symptoms of a problem or event and you will have a much more robust solution in place. This is because the solution(s) are more effective when accomplished through a systematic process with conclusions backed up by evidence.

When you step back and consider what the DOJ was trying to accomplish with its 2023 ECCP, it becomes clear what the DOJ expects from the compliance professional. Consider the structure of your compliance program and how it inter-relates to your company’s risk profile. When you have a compliance failure, use the root cause analysis to think about how each of the structural elements of your compliance program could impact how you manage and deal with that risk.

 

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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