JCAHO revises sentinel event policy
JCAHO will 'vigorously defend confidentiality'
In a "Sentinel Event Update" issued in January by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, the agency announced the following procedural changes to its sentinel event policy:
· Organizations will be asked not to disclose the names of patients and caregivers involved in sentinel events when reporting information to the Joint Commission.
· The organization reporting a sentinel event will be expected to submit two separate documents, a root-cause analysis (RCA) and the resulting action plan that describes the organization's risk-reduction strategies.
· Once key information from the RCA has been entered into the Joint Commission's database, the RCA will be returned to the organization. Where the RCA requires consideration by the accreditation committee, all copies will be destroyed once the committee has concluded its review.
· Once the action plan has been implemented to the satisfaction of the Joint Commission, it too will be returned to the organization.
· The Joint Commission will include language in its future Application for Survey and Terms of Agreement document (the contract between the Joint Commission and the organization) that will formally recognize the Joint Commission as a participating entity in the organization's quality monitoring and improvement activities. That is, the Joint Commission would be explicitly portrayed as part of, not separate from, the organization's work to reduce the risk of future sentinel events. That tactic is designed to help preserve the confidentiality of peer review information. Until this contract revision is in place, the Joint Commission will, if requested, provide written documentation of that to the organization.
· The Joint Commission will make available on-site assistance to organizations in preparing RCAs for a fee limited to direct costs.
In its statement, the Joint Commission said it will not disclose sentinel event-related information to third parties and will vigorously defend its confidentiality, if necessary, in the courts.
In addition, the Joint Commission stated it will consider developing legislative and regulatory remedies to close confidentiality gaps. To that end it formed a task force in collaboration with the American Hospital Association, the American Society of Hospital Risk Managers, the American Medical Association, the American College of Physicians, and state hospital associations to conduct a thorough assessment of applicable laws and protections. The task force will perform detailed state-by-state analyses of existing confidentiality protections to see how state-specific adaptations in the contract between the Joint Commission and organizations can reduce existing concerns about confidentiality protections.
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