JCAHO to use ORYX data to detect sentinel events

Consult with risk manager before opting out

On Sept. 30, the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Health care Organizations (JCAHO) circulated a memo to 60 hospitals, informing them that at least one of the indicators they had selected for the ORYX initiative will be used to collect information about sentinel events at the facilities. (See memo text, below.)

What’s more, if the Joint Commission learns of a sentinel event through a hospital’s quarterly ORYX report, it will regard that event as having been self-reported by the organization. The good news is that the Joint Commission is offering an escape clause to organizations that unknowingly selected one of the 13 "sentinel event indicators": Those organizations can choose to drop the indicator in question and select one that doesn’t relate to sentinel events at all.

Ceil Stern, director of accreditation and licensure at the New Jersey Hospital Association in Princeton, approves of the Joint Commission’s decision to allow hospitals to opt out if they’re not comfortable using one of the sentinel event indicators, but says the new policy still "opens up a can of worms where you’re just trying to comply with selecting indicators for ORYX. For institutions that choose not to report, this is like a forced report which triggers other actions."

Hospitals should be particularly wary if their state doesn’t offer protections that keep sentinel event information confidential. "There are states that mandate reporting of sentinel events to the Department of Health," Stern notes.

"Health care facilities need to decide whether they’re comfortable persevering [with these indicators] under their existing state laws," says Fay A. Rozovsky, JD, principal of the Rozovsky Group in Richmond, VA. "If they are, fine. But if not, then they’re opening another vista for sentinel events."

ORYX Measures Identified as Potential Reviewable Sentinel Events
Measure ID	Program Code	Measure Short Name
1625	HAP	Neonatal mortality rate greater than 2500 gm
2936	HAP	Neonatal/intrapartum fetal deaths at or after 34 weeks
2967	HAP	Maternal death rate
2985	HAP	Suicide deaths, inpatient adult behavior program
3091	HAP	Obstetrics clinical service mortality
3878	HAP	ABO incompatibility — all DRGs
4311	HAP	Vaginal delivery mortality
4320	HAP	C-section delivery mortality
4821	HAP	Severe adverse drug reactions
5033	HAP	Risk-adjusted obstetrics mortality rate
9577	HAP	ABO incompatibility
10896	BHC	Deaths by suicide in inpatient adult bh program
11101	HAP, LTC	Harmful medication errors

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Rozovsky says quality managers should consult with their facility’s risk manager before making any decision on the use of one of the 13 indicators. (For a list of the indicators in question, see box above.) "If you’re not comfortable dealing with sentinel events from an evidentiary protection point of view, you may not see it as an issue," she says. "Right now is a good time to start really looking into the use of these kinds of ORYX indicators to make sure it’s consistent with the overall policy and procedures of the health care facility as it relates to sentinel events reporting."

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