ASHRM to JCAHO: Give hospitals game rules
Suspension of implementation requested
This past March, the Chicago-based American Society for Healthcare Risk Management (ASHRM) issued a position statement regarding the Joint Commission's sentinel event policy. (To see ASHRM's position statement in its entirety, access http://www.ashrm.org/JCAHO/jcahopos.htm on the Internet.) The organization identified several significant problem areas and made the following commentary:
· Confidentiality, discoverability, admissibility, and disclosure. A facility may avoid compliance with the sentinel event policy for fear of its financial and reputational consequences. Compliance may place an organization at risk for disclosure of the sentinel event information.
· Reporting deadlines. The deadlines imposed do not provide organizations with sufficient time to gather reliable information about the event, report it, and perform an RCA. Forcing organizations to adhere to strict reporting deadlines strains their already limited resources and diverts attention to compliance rather than improvement efforts.
· RCA format. Organizations should be allowed to craft tools that best suit their own needs for documenting RCA results. The Joint Commission should publish criteria regarding the types of information to be included, but should not prescribe how that information be organized or documented.
· Definition of a sentinel event. The phrase "risk thereof" should be deleted from documents that describe the sentinel event program. The revised definition of a sentinel event, while more clearly identifying broad categories of reportable incidents, continues to incorporate the phrase thereof," and that generates opportunities for confusion and misinterpretation on the part of health care organizations and surveyors alike.
· Criteria for a "thorough and credible" RCA. The Joint Commission should publish meaningful and measurable criteria by which an RCA will be evaluated so that organizations will have a clear understanding of how their work will be judged. Evaluations must incorporate and adequately represent the risk management processes by which sentinel events will be investigated and root causes identified.
Financial and reputational consequences
ASHRM requested that the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, suspend its sentinel event reporting program until the issues raised could be resolved. Yet at a Feb. 13 meeting, the accrediting agency resolved to retain the program in its original form. In a statement posted at its Web site, ASHRM states its disappointment in the Joint Commission's position that the program be maintained in the face of serious unresolved concerns regarding confidentiality and other significant obstacles to compliance. ASHRM's statement says the Joint Commission's position reflects a continued lack of understanding about the nature of the concerns of health care organizations regarding the sentinel event program and actions necessary to resolve these concerns.
Nancy Rapp, RN, risk manager for the Alliant Health System in Louisville, KY, and a member of ASHRM's board of directors, says: "I've talked with several risk managers who feel it's as though JCAHO developed a board game and expects everyone to play, but forgot to include a complete set of instructions. The definition is ambiguous, the process unclear, the legal concerns looming."
Rapp says ASHRM's task force for the Joint Commission met in March with representatives of the Joint Commission to address continued concerns regarding:
· "legal minefields" of sharing RCA information;
· risks inherent in using the suggested RCA form;
· ambiguous sentinel event definition;
· epidemiological concern about the validity of data entered into the proposed database of national sentinel event information;
· confusion concerning reporting deadlines and requirements.
Furthermore, she says, affixing the status of accreditation watch on an entity in which a sentinel event has occurred is perceived as punitive and potentially damaging to the facility's reputation.
In the interim, ASHRM encourages accredited organizations to carefully consider the risks and benefits of complying with the Joint Commission's sentinel event reporting program.
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