Joint Commission alters sentinel events policy
The Oakbrook Terrace, IL-based Joint Commis-sion on Accreditation of Healthcare Organiza-tions has modified the Alternative 4 section of its sentinel events policy for organizations that have experienced sentinel events but have significant legal concerns about sharing information on the event information 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 the Joint Com-mission. This review process includes interviews of organization staff and review of relevant documents to obtain information as to how the organization approaches the evaluation of a sentinel event.
In addition, the CEO 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.
The Joint Commission’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 the reviews.
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