JCAHO halts enforcement of recent needle alert

Alerts to be reviewed, limiting impact on scores

Surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will not score hospitals on their compliance with Sentinel Event Alerts, including a recent alert on needle safety. The temporary moratorium will give the Joint Commission time to review all Sentinel Event Alerts and determine which ones should impact scoring, says Richard J. Croteau, MD, executive director for strategic initiatives at the Oakbrook Terrace, IL-based accrediting agency.

Surveyors still will ask about needle safety in the context of JCAHO standards, Croteau says. "The current expectation on our part is that organizations will be in compliance going forward with those recommendations that were published in that alert, but we’re not going to be scoring. We won’t be enforcing [compliance]," he says. "If surveyors determine that the organization has not paid attention to recommendations in the Sentinel Event Alert, they will then look at the standards that are relevant to that topic and then evaluate if the organization is in compliance with the standard," Croteau says.

How this action will affect the surveyors’ focus on needle safety is unclear. Noting that the Joint Commission requires compliance with "applicable laws and regulations," the Sentinel Event Alert published in September informed hospitals that surveyors would assess organizational compliance with the Needlestick Prevention and Safety Act. (See Hospital Employee Health, March 2001, "OSHA issues needle safety regulations.") The moratorium was to be published in the January issue of Joint Commission Perspectives.

The federal law directed the Occupational Safety and Health Administration (OSHA) to revise its bloodborne pathogen standard to require employers to use needle safety devices. They also must involve frontline employees in the selection of devices and maintain a needlestick log. (For more information on the law and standard, see HEH, December 2001, "New Year’s gift: Rule offers record-keeping relief.") As the alert noted, several other standards could be interpreted to require compliance with needle safety, including governance, management, environment of care and prevention, and control of infection.

Hospitals worried about compliance burden

However, the Joint Commission surveyors are not surrogate OSHA inspectors, Croteau stressed. "We’re surveying for compliance with our standards. That’s it."

Advocates for worker safety had welcomed the agency’s September Sentinel Event Alert on needlestick prevention and expected the action to have broad impact. After all, few hospitals ever see an OSHA inspector, while surveyors visit accredited facilities every three years. They expressed shock and disappointment at the Joint Commission action.

"We were very hopeful with the publication of the Sentinel Event Alert," says Susan Wilburn, RN, MPH, senior specialist for occupational safety and health for the American Nurses Association (ANA) in Washington, DC. The Joint Commission has a much greater influence on hospitals than OSHA, she says. The ANA had hoped to work with the Joint Commission on other alerts that would address worker safety, Wilburn says. "We want more [protection], not less."

"It is a vivid illustration of the conflict inherent when we cede oversight authority for the quality and safety of the health care environment to a private industry funded and controlled group to perform what is essentially a government and public health function," says Bill Borwegen, MPH, occupational health and safety director of the Service Employees International Union in Washington, DC.

The alerts presented new compliance issues for hospitals. "There were some concerns raised about the number of Sentinel Event Alerts that had been published and are continuing to be published, roughly once a month — the amount we were asking organizations to respond to and the burden that might represent on resources," says Croteau. "There also were questions raised about the evidence base or expert consensus that was backing up the alerts."

The Joint Commission will convene an expert panel to review all Sentinel Event Alerts. "We will select a finite number of specific evidence-based, cost-effective recommendations that we feel organizations should respond to. We’ll go ahead and survey [on] those," he says. While there isn’t a timeline that indicates when surveyors will begin assessing compliance with the alerts, Croteau says he expects the activities to resume in 2002. Meanwhile, he stresses that the Joint Commission never intended for Sentinel Event Alerts to be new standards or regulations. "Our whole accreditation process is as much consultation as it is compliance. It’s an improvement process, not a regulatory process."

Even when surveyors include the alerts in their assessments and scoring, they will not expect rigid compliance, Croteau says. "We want [organizations] to be aware of what’s in the alert and consider it, and either follow the recommendations that are there or some other reasonable alternative. They can decide to do something different, as long as it’s reasonable," he says. "We feel it’s important not to be too directive with organizations as to how to do things because that would in effect stifle innovation. We want them to figure out better ways to do things," he explains.