HCAHO alters its sentinel event policy
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, has modified the Alternative 4 section of its sentinel events policy for organizations that have experienced sentinel events but that have significant legal concerns about sharing information on the event with the Joint Commission.
Under Alternative 4, an organization may opt to have a specially trained surveyor conduct an on-site review of the organization’s response to a sentinel event, rather than provide the root-cause analysis of the sentinel event to JCAHO. This review process includes interviews of organization staff and review of relevant documents to obtain information on how the organization approaches the evaluation of a sentinel event.
In addition, the chief executive officer of the organization is required to affirm in writing that use of any other alternative for review under the sentinel event policy would increase the risk of waiving existing confidentiality protections for the information.
In continuing the availability of Alternative 4, the board made the following significant modifications to the review protocol:
• At the time of the on-site Alternative 4 review, the surveyor will conduct a standards-based evaluation of the patient care and organization management activities that are potentially relevant to the sentinel event.
• In addition to affirming in writing that use of any other alternative would increase the risk of waiving existing confidentiality protections for the information, the organization must attest that a thorough and credible root-cause analysis has been conducted for the sentinel event under review.
JCAHO’s board made the decision after an intensive review of actual field and Accreditation Committee experience during the one-year pilot test of the Alternative 4 protocol. Comments were also solicited from the American Hospital Association, Joint Commission advisory committees, organizations that had participated in Alternative 4 reviews, and surveyors who had conducted these reviews.
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