JCAHO modifies sentinel event reporting option
On-site reviews now on deck
The Board of Commissioners of the Joint Commission on Accreditation of Healthcare Organizations has modified and continued an important reporting option — known as Alternative 4 — for organizations that have experienced sentinel events but have significant legal concerns about sharing sentinel 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 a root-cause analysis of the sentinel event to the Joint Commission. That review process includes interviews with organization staff and a review of relevant documents to obtain information as to 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.
Protocol modified
In continuing the availability of Alternative 4, the board made these significant modifications to the review protocol:
1. 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.
2. 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 board acted following an intensive review of the field and accreditation committee experience during the one-year pilot test of the Alternative 4 protocol. Comments also were 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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