Catastrophic error triggers accreditation watch
A simple personnel change won’t hack it
A resident who has slept three hours in two days misreads a chart and makes a grave mistake. Easy problem to solve: just fire the resident, right?
It’s not that easy anymore. Of course, the tenants of TQM dictate that blame should not be placed on the person but on the process. And now the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, is backing its commitment to QI through a new policy for hospitals when a major medical error occurs.
Number of facilities on watch’ grows
Since September, the Joint Commission has placed about a dozen such facilities on "accreditation watch," a notation available for public information. The watch status is appended to the hospital’s existing accreditation classification until a corrective plan is in place.
It is public in the sense that when a consumer calls the Joint Commission asking about the status of a particular hospital, the Joint Commission will release the fact that the hospital is on accreditation watch if that is the case. The Joint Commission will not release a list of all hospitals on accreditation watch.
An adverse event triggers an interim survey of the facility within two weeks of the Joint Commission’s learning of the sentinel event. If the surveyor determines the organization could have had control over the circumstances that led to the event, the organization is placed on accreditation watch. The burden is on the organization to prove that it could not have controlled the circumstances that led to the event.
During the survey, the Joint Commission scrutinizes the processes that resulted in the error and requires the hospital to develop a plan to prevent these errors from recurring.
Within 30 days, the organization is required to provide the Joint Commission a written summary of a root-cause analysis. The analysis should focus primarily on systems and processes, not individual performance, and identify changes to reduce the risk of sentinel events in the future. The organization must implement the system and process improvements and apply a system for evaluating the effectiveness of the improvements.
"We want to get people to focus on the process and how to correct it," says Rick Croteau, MD, vice president of accreditation services at the Joint Commission. "If it was a human error, we have to find out if it was a problem with communications, if it was related to training, or if there was some step that broke down."
Surveyors act as consultants
According to Croteau, surveyors are available to provide information to the hospital on how to go about doing root-cause analysis and work with the appropriate people via telephone and mail in a consultative role. "Our goal is to improve processes and reduce risks, and we’re available to help hospitals develop solutions."
The hospital will need to bring a group of people together who all have the same understanding of a particular process, explains Judy Houma-Lowry, RN, MSBA, CPHQ, a quality consultant based in Detroit. Only then can a team determine what caused the error and develop a plan to ensure the situation does not repeat itself.
"Overall, this is a great thing for hospitals," she says. "They will have to focus on the real issue, on why people make mistakes."
The new watch status should correct glitches in the old system, Croteau says. Under the old policy, a hospital that committed an error resulting in the injury or death of a patient was placed on "conditional accreditation," a status that implied the facility was not meeting some Joint Commission standards. "That might not have been true," Croteau says. "Someone can make a deadly mistake at a hospital that is meeting all of our standards."
More important, the old policy failed to address procedures whereby facilities solved the problem by firing someone. Under the new system, a simple personnel change will not be viewed as enough to correct the problem, Croteau says.
New approaches to be included
In addition, Croteau says, the Joint Commission plans to learn more about the nature of sentinel events and related process improvements, as well as new approaches to designing risk reduction strategies. The Joint Commission plans to apply some engineering design methodologies, such as those used in the airline, nuclear power, and chemical industries, to designing processes to minimize risk and error.
The Joint Commission board also approved a new definition of sentinel event: "an unexpected occurrence, involving death or serious physical or psychological injury or risk thereof. Serious injury specifically includes loss of limb or function. The event is called sentinel’ because it sends a signal or sounds a warning that requires immediate attention."
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