Sentinel Event Alerts still useful, but not for scoring
Risk managers can breathe a sigh of relief now that a much-criticized plan to use the Joint Commission’s Sentinel Event Alerts for scoring is being abandoned, for now at least. But don’t let down your guard entirely: the plan could be revived at a later date and the Joint Commission still expects you to put the Alert information to use.
For months, the Joint Commission planned to use the Sentinel Event Alerts for calculating a hospital’s patient safety management score. Published periodically by the Joint Commission, the Sentinel Event Alerts focus on a particular type of sentinel event and provide advice on how to avoid them. Under the original plan, the Alerts were to be used as criteria for determining how well a hospital has addressed patient safety. Surveyors would consider each Alert as a lesson on that particular hazard and then accredited hospitals would have to put those lessons to use.
Risk managers and other hospital leaders were highly skeptical of the plan, according to Ken Shull, FACHE, president of the South Carolina Hospital Association in West Columbia. Shull chairs the Joint Commission’s Accreditation Process Improvement Implementation Task Force. He says many risk managers feared the plan was just unrealistic, that the Joint Commission was expecting hospitals to move too quickly in response to the Sentinel Event Alerts.
Recently, in response to that criticism, the Joint Commission announced "a moratorium on the scoring of health care organization with Sentinel Event Alert recommendations." Surveyors will not score hospitals on compliance with the alerts and figure that into the facility’s patient safety management score, but that’s not necessarily the end of the story. The Joint Commission makes clear that risk managers still should pay close attention to the Alerts and incorporate its lessons whenever possible. Spokeswoman Janet McIntyre also notes that the plan was not killed off entirely. The moratorium could be lifted at a later date, she says.
"Current standards require organizations to review all Sentinel Event Alert recommendations, determine their applicability to their organization’s services and, where applicable implement the recommendations or reasonable alternatives within 90 days of publication in Joint Commission Perspectives," according to the Joint Commission statement. "Although the implementation of recommendations will not be scored during the moratorium, surveyors will assess, for consultative purposes, the organization’s knowledge of Sentinel Event Alert recommendations and how the organization plans to implement these recommendations."
The statement says, "Although the implementation of recommendations will not be scored during the moratorium, surveyors will assess, for consultative purposes, the organization’s knowledge of Sentinel Event Alert recommendations and how the organization plans to implement these recommendations."
With the assistance of the state hospital association-based Accreditation Process Improvement (API) Implementation Task Force, the Joint Commission is developing a revised approach to the publication and survey of Sentinel Event Alert recommendations. The revised approach will address concerns regarding the frequency and content of Sentinel Event Alerts and the number of Alert recommendations subject to survey each year. At a recent meeting, the API Task Force recommended decreasing the frequency of publication of Sentinel Event Alert; establishing a standing Sentinel Event Alert advisory expert panel to assess the validity and practicality of recommendations; and identifying a limited number of Sentinel Event Alert evidence-based recommendations that would be the focus of on-site surveys for one year.
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