Moratorium is extended on JCAHO’s alert scoring

Panel will select national goals for compliance

Hospitals undergoing accreditation won’t be scored on Sentinel Event Alerts such as a recent one on needle safety, unless the alert relates to one of six National Patient Safety Goals set by an expert panel, the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, announced.

The action represents a tightening of focus for the Joint Commission, which placed a moratorium on scoring related to the alerts in January. While hospitals are still expected to respond to the alerts, surveyor comments will be consultative only.

Has JCAHO reneged’ on its obligation?

The announcement came as a surprise to some who had hoped the Joint Commission would have a major impact on implementation of safer sharps devices in the nation’s hospitals by monitoring compliance with the needle safety alert.

"We would have saved the lives of a number of health care workers," says Bill Borwegen, MPH, occupational safety and health director of the Service Employees International Union (SEIU). "But JCAHO reneged on [its] responsibility to make the workplace safer for health care workers."

The patient safety goals will be chosen based on past issues of Sentinel Event Alert by a panel of physicians, nurses, risk managers, and "other health care experts," the Joint Commission said. The first goals will be released this July and, as of Jan. 1, 2003, surveyors will check for compliance with the recommendations or "implementation of an acceptable alternative."

Hospitals can receive a Type I recommendation if they are not in compliance with those goals.

"These six goals are essentially going to replace the survey compliance for all of the Sentinel Event Alerts," says Janet McIntyre, Joint Commission spokeswoman.

In a statement, Dennis O’Leary, MD, president for the Joint Commission, said the goals are part of "intensive efforts to reduce errors in health care. . . . Great strides are being made in improving patient safety, but we want organizations to concentrate on widely recognized vulnerabilities in the way care is provided."

Needle alert was first ever for HCWs

The Joint Commission has a longstanding partnership with the Occupational Safety and Health Administration (OSHA), and its surveyors often ask about needle safety devices or bloodborne pathogen exposures.

But the alert issued in September 2001, the first ever that related to worker safety, placed greater emphasis on needlestick prevention. In that alert, the Joint Commission said its surveyors would assess compliance with the Needlestick Prevention and Safety Act of 2000, including requirements for detailed needlestick logs and involvement of frontline workers in device evaluation.

When the Joint Commission announced a moratorium on scoring related to the alerts, JCAHO officials insisted that they never intended to become surrogate OSHA inspectors. "Our whole accreditation process is as much consultation as it is compliance," said Richard J. Croteau, MD, executive director for strategic initiatives.

"It’s an improvement process, not a regulatory process," he said.

While surveyors won’t score based on compliance with the act, the accrediting body still requires hospitals to comply with "applicable laws and regulations." Surveyors are likely to still ask for documentation related to bloodborne pathogen exposures and efforts to reduce them.

Hospitals had complained about the burden of responding to monthly Sentinel Event Alerts and questioned whether they were evidence-based. The new Sentinel Event Alert advisory panel will "assess the evidence for and validity of past and future Sentinel Event Alert recommendations, as well as the practicalities of implementation," the Joint Commission said. Each July, the next year’s goals will be announced, with some goals continuing and others replaced with higher priorities, the agency said.

Amid the Joint Commission’s announcement, some wondered whether OSHA would step up compliance activity related to the revised bloodborne pathogen standard.

"What remains to be seen is how aggressive OSHA is," says Geoff Kelafant, MD, MSPH, FACOEM, medical director of the occupational health department at the Sarah Bush Lincoln Health Center in Mattoon, IL, and chairman of the Medical Center Occupational Health Section of the American College of Occupational and Environmental Medicine in Arlington Heights, IL.

OSHA has announced that it would step up inspections of employers with above-average injury rates, which includes the hospital sector.