What's going on with JCAHO's sentinel events policy?
Agencies may choose not to report problems unless media forces issue
(Editor's note: This is the first in a series of stories on the sentinel events policy of the Joint Commission on Accreditation of Healthcare Organizations. Next month, we'll focus on how home care agencies can conduct root-cause analyses.)
Home care agencies have been scrambling since November to decide what to do about the revised sentinel events policy of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL.
Some experts predict that most home care agencies will choose not to voluntarily report sentinel events except in cases where the problem already has been published in local newspapers.
"The consensus among risk management people in Chicago is if the incident that occurs shows up in the newspaper, they're going to report it to the Joint Commission, but other than that they won't report anything," says Peggy Cwik, ARM, RN, a senior health consultant with AIG Health Care Management Services, a health care consulting company in Chicago.
Cwik is part of the Home Health Care Think Tank, a committee of the Chicago-based American Society for Healthcare Risk Management (ASHRM). The committee began meeting in February and has a goal of pulling together resources to explore risk and quality issues in home care.
The Joint Commission has asked all accredited hospitals, agencies, and other facilities to voluntarily report to JCAHO any incidents involving accidents and errors that harm patients.
The Joint Commission's purpose in requesting these voluntary reports is to gather information and develop strategies that may reduce the risk of health care accidents and errors, says Janet McIntyre, JCAHO spokeswoman.
"In the past we learned about sentinel events through the media and news organizations," McIntyre says. "Now we're trying to track them and build a database."
This has created a dilemma for some home care agencies. On the one hand, they want to cooperate with the Joint Commission. But on the other hand, they do not want to place themselves at legal risk by sending the Joint Commission information that could be sought in a subpoena by a third party, says Patrice Spath, ART, a consultant in health care quality and resource management in Forest Grove, OR.
What makes it more confusing is that JCAHO requires agencies to conduct an internal root-cause analysis of each sentinel event. Reporting these events is voluntary, but conducting the root-cause analysis is a requirement for all accredited agencies. And any agency that reports its sentinel events also must show the Joint Commission its root-cause analysis. (See the Joint Commission's sentinel event policy, p. 92.)
So the Joint Commission has made some changes to its sentinel events policy, and these changes say agencies do not have to send documentation along with their reports of sentinel events.
"A root-cause analysis does not have to be on a piece of paper," McIntyre says. "The whole idea is to ask the question 'why,' and dig down deep and examine systems and policies. But there is no prescribed format."
JCAHO offers on-site reviews
The Joint Commission decided to alleviate fears about confidentiality of root-cause analyses by offering health care organizations two alternatives to sending JCAHO the written material, McIntyre says.
One option would be to have the Joint Commission come to the facility to look at the written root-cause analysis, McIntyre says. The Joint Commission would charge $3,500 for this on-site review.
If an agency decides to keep no written documentation of the root-cause analysis, then the Joint Commission could come and interview employees about the event, McIntyre says.
"All sentinel events do require a thorough examination," McIntyre says. "So if you don't voluntarily report it, it doesn't mean that a thorough examination doesn't need to be done."
Alliant Health System in Louisville, KY, is taking a wait-and-see attitude about voluntarily reporting sentinel events, says Nancy Rapp, RN, risk manager for the health system, which has 1,000 beds, a home health agency, and multispecialty facilities.
"We are certainly concerned about the legal ramifications and exposure possibilities if we report," Rapp says. "We will take this on a case-by-case basis."
Lifeline Home Health Services in Garland, TX, has plans to report sentinel events to JCAHO, says Laura Tanner, RN, quality assurance and improvement director of the full-service, freestanding home care agency that serves the Dallas metropolitan area and western Texas.
Tanner says she agrees with the Joint Commission's goal of improving patient care through gathering this information. "The policy sounds more punitive than it actually is," she says. "The Joint Commission is doing it to improve patient care, not to see if they can catch you making a mistake."
If you're still confused about the sentinel event policy, here is a quick guide to what it's all about and what it might mean to you:
What it is: The Joint Commission's sentinel event policy asks that health care organizations report only the events that meet the following criteria:
· The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition, or;
· the event is one of the following (even if the outcome was not death or major permanent loss of function):
- suicide of a patient in a setting where the patient receives around-the-clock care;
- infant abduction or discharge to the wrong family;
- rape;
- hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities;
- surgery on the wrong patient or wrong body part.
The Joint Commission's sentinel event policy requires accredited agencies to conduct a root-cause analysis of sentinel events and other significant occurrences.
JCAHO surveyors will do on-site reviews of an agency's root-cause analysis or on-site interviews with a review of relevant documentation. These will cost an agency $3,500 per review. Any agency that declines to share this information with the Joint Commission will be placed on accreditation watch, risking the loss of accreditation.
When: The Joint Commission revised its policy in November 1997 and it became effective on April 1, 1998. On-site reviews will be available on July 1, 1998.
Any agency that decides to voluntarily report a sentinel event to the Joint Commission must do so within five days of learning of its occurrence. Then the agency must conduct a root-cause analysis and make that information available to the Joint Commission within 30 days. All agencies that do not report their sentinel events also must conduct root-cause analyses within 30 days and have that information available in case the Joint Commission finds out about it and asks to see it.
How: Alliant Health System has a critical incidence/sentinel event process that includes identifying the event, investigating the event, and determining the appropriate employees who should be involved, Rapp says.
"A multidisciplinary group looks at the event to prevent it from happening again," Rapp adds.
Cwik says home care agencies sometimes first hear about a sentinel event involving one of their patients only after the incident has been reported in the newspaper or is brought to their attention by a state agency.
This happens when a patient is disgruntled and decides to report a problem to a third party instead of reporting it to the agency.
"I think the important thing is that home care agencies feel confident that they have a program in place that makes sure they know about these incidents and that they're getting reported when they happen," Cwik says.
The Joint Commission advises organizations to do the following when they conduct a root-cause analysis:
· Discover what happened.
· Find out why it happened, and what processes and systems were involved. What was the cause? What processes were involved? What systems underlie those processes?
· Identify the root cause through "why did it happen" questions.
· Identify action plans and solutions for each root cause.
· Measure outcomes of risk-reduction strategies and put measurement plan into effect.
· Collect and analyze data to document that improvements have occurred.
(Homecare Quality Management will present details on how agencies may conduct root-cause analyses in the second part of this series, to be published in the July issue.)
Why: For years the Joint Commission has collected information about sentinel events in health care organizations, based on information reported in newspapers and other publications.
Sometimes these events could have been prevented if the organization had recognized its faulty processes and corrected them before the sentinel event occurred. (See story on how data collection may reduce accidents, below.)
Some medication errors are caused by misunderstandings about how a bottle is labeled. For instance, a common mistake has involved potassium chloride. Confusion over how it is labeled has led to a patient being given potassium chloride that is not diluted, McIntyre says.
"So the Joint Commission sent out an alert to all health care organizations we accredit and said, 'This is what we have seen, and this is what you might want to consider,'" McIntyre says.
If the Joint Commission had greater access to information about these types of errors, it could do a better job of alerting other organizations to commonplace mistakes, therefore helping all health care organizations improve safety, McIntyre adds.
Theoretically, this can work, Spath says.
"By letting us know about it, then we can dig into our processes and improve these processes before we have a bad event ourselves," Spath explains. "So the concept is a good one."
[Editor's note: The Chicago-based American Society for Healthcare Risk Management (ASHRM) will hold an audio conference on sentinel events and risk management on Aug. 6, from 1 p.m. to 3 p.m. central time. For more information, you may contact ASHRM at (312) 422-3988 or at its Internet site: http://www.ashrm.org.]
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