JCAHO Revamps Sentinel Events Policy

Voluntary approach carries bigger penalties

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has adopted new policies for its sentinel event Accreditation Watch program that will take effect in April. In a carrot-and-stick approach, the reporting of a sentinel event now becomes voluntary, but the inclusion on Accreditation Watch and the possibility of public disclosure is heightened if the JCAHO finds out about a problem from any other source than the health care provider involved.

The agency defines a sentinel event as, "An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof."

From there, if two of three criteria are met to further determine a sentinel event, then the new policy kicks in. Those criteria state that the event:

o resulted in unanticipated death or major permanent loss of function;

o is associated with significant deviation from usual process or processes;

o has undermined, or has significant potential for undermining public confidence.

Under the new policy, if a health care organization believes such an event has occurred and reports it to the JCAHO within five days of discovery, Accreditation Watch won’t take place automatically. Instead, the provider is given 30 days to submit a report focusing on what the Joint Commission calls a "root cause analysis," covering how the event occurred and how it can be corrected for the future. (See "Framework for Conducting a Root Cause Analysis," insert.)

The JCAHO is offering a guidebook, or framework, to help health care systems adhere to this root cause analysis. If the Joint Commission learns of a sentinel event itself, automatic Accreditation Watch does kick in, an on-site visit is likely, and the same 30 days is given to submit the root cause analysis for consideration.

[For more information, contact the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Telephone: (630) 916-5600.]