Please help: You are the Quality Assurance/Quality Improvement Director for the medical center. As a member of the QA/QI

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Please help:
You are the Quality Assurance/Quality Improvement Director for
the medical center. As a member of the QA/QI Committee, you
have been asked to analyze and recommend improvements to the
Sentinel Event Policy :
B. Determination
of Reporting of Sentinel Events to TJC
The Hospital shall perform a Root Cause Analysis for Sentinel
Events and shall evaluate reporting Sentinel Events to TJC after
consultation with Home Office Senior Director of Quality Management
and Regulatory Counsel.
analyze Sentinel Event policy for deficiencies by
comparison with two other sentinel event policies found from
research