Fear of reprisal defeats purpose of reporting
Though risk managers support the idea of investigating the root cause of adverse events and then correcting deficiencies, the Joint Commis-sion on Accreditation of Healthcare Organiza-tions' (JCAHO) sentinel event policy defeats the purpose of such investigations by causing health care providers to fear reprisal if they're forthcoming with information. That complaint is at the heart of the American Society of Healthcare Risk Management's argument with JCAHO over changes in the sentinel event policy.
ASHRM's position statement says the sentinel event policy "poses a significant threat to the effectiveness and viability of such early warning systems, imperiling the free flow of information within healthcare organizations of all types." The group goes on to say that problems with the policy "can have the unintended and highly undesirable effect of inhibiting the reporting and investigation of sentinel events within organizations, effectively driving such information `underground.'"
Here is a summary of the problems outlined by ASHRM:
· Confidentiality, discoverability, admissibility, and disclosure of sentinel event information.
There is little uniformity among state and federal laws regarding these issues. Patient care information is protected in many jurisdictions, but that protection may be waived when the information is disclosed to parties outside the facility, including JCAHO.
Information reported to the Joint Commission would be pursued vigorously by attorneys, and JCAHO uses terms such as "proximate cause," "error," and "human error" that could be misinterpreted as an admission of liability. A corrective action plan could be construed as evidence of previous substandard care.
There also may be a conflict with the concerns of insurers, who insist on prompt reporting of adverse events but also that they not be discussed with any third parties. That can create a conflict with JCAHO's reporting requirements, especially if an attending physician under a different insurer will not cooperate with the root cause analysis because cooperation would represent a violation of the agreement with the physician's insurer.
· Reporting deadlines.
Providers must report a sentinel event to JCAHO within five business days of the event or of becoming aware of the event. The root cause analysis then must be delivered within 30 days. But organizations often have no knowledge of a sentinel event right away, and even when the event becomes known, it may take more than five days to determine whether it meets JCAHO's criteria for a sentinel event. Likewise, a thorough and credible root cause analysis may take much longer than 30 days to complete.
· Root cause analysis format.
The Joint Commission has provided an approved format documenting the root cause analysis and expects health care organizations to use it or one substantially like it. But the format is cumbersome and not easily applicable to all situations, and it contains incriminating language that could harm an organization significantly if disclosed. Also, the format is overly prescriptive and doesn't allow sufficient flexibility.
· Definition of "sentinel event."
The recently revised definition still uses the phrase "risk thereof," which creates opportunities for misinterpretation on the part of health care organizations and surveyors alike. Focusing on situations that present risk of injury diverts attention and resources from those in which injury actually did occur. Although JCAHO has stated in a letter to ASHRM that it does not expect facilities to report and submit root cause analyses for situations involving only the risk of injury, that clarification does not appear in JCAHO's policy statements.
· Criteria for a "thorough and credible" root cause analysis.
JCAHO requires that a root cause analysis be "thorough and credible," but it has not published criteria for assessing those qualities. ASHRM is aware of instances in which the Joint Commission repeatedly has rejected an organization's root cause analysis. JCAHO has offered to provide assistance to facilities that have difficulty completing a satisfactory root cause analysis, but the facilities must pay a fee for that assistance. Also, the guidance provided so far on how to conduct a root cause analysis does not sufficiently incorporate risk management processes.
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