TJC suspends 'auto' adverse decision

The Joint Commission has suspended its policy that triggers an "automatic" adverse decision if an organization fails to complete an acceptable root-cause analysis in response to a sentinel event or its related measure of success within a specified time frame. The change is retroactively effective as of Jan. 1, 2010.

Under the new policy, if an organization makes "measurable and observable" efforts to improve and mitigate a risk of recurrence, The Joint Commission will consider the organization's efforts before changing its accreditation status.

"It is no longer automatic that an organization will be placed into provisional status, which puts them on the path to other actions — up to and including an adverse accreditation decision — based on some part of the process on which they did not completely hit the mark," explains Anita Giuntoli, BSN, RN, MJ, associate director of the office of quality monitoring at The Joint Commission. "So, for example, if they have done a really good root-cause analysis, but when they implemented and measured their new processes it did not hit the thresholds that were set, we will work with them on what the obstacles are and what steps will make this process more effective for them."

In the case of an ED, for instance, the remedy might have been education of the ED staff. "That's something you can measure, like the percentage of nurses for whom education had to take place within three months," Giuntoli says. In that example, perhaps the ED had set a target of 95% of the nurses being educated within three months but they had only reached 85% because the educators had not yet educated the night shift, she says.

"We'll ask what they're going to do now to tweak their plan, and we look to them to be responsive," says Giuntoli. "Perhaps they'll decide to assign two more nurses to cover the night shift or have a 'learn at breakfast' session."

If the changes seem to give them a reasonable chance of meeting expectations, The Joint Commission might suggest they touch base again in a few weeks or a couple of months "to see if things are moving along a constructive path." If, on the other hand, there had been no substantive effort toward implementing the plan and measuring what occurred — i.e., "we scheduled a lunch and learn but nobody showed up" — "then we would say that might trigger a cascade of more serious discussions," Giuntoli adds.

Who does the reporting?

The direct reporting of an adverse or sentinel event to The Joint Commission is not handled by the ED manager, even if the event occurred in the ED, notes Mary Anne Morris, MS, RN, senior director of accreditation services for Cincinnati Children's Hospital Medical Center.

"That responsibility resides in a position like mine, or it may be done through the legal department," Morris says. "You're required to report an event if it becomes public knowledge, for example, if something appears in the paper."

She adds that because The Joint Commission uses a service that saves news reports, the agency certainly will know about it. In that case, even if the event occurred in the ED, someone in her position would make the report directly. However, if an ED patient is given the wrong dosage of a medicine and there is an adverse outcome, it might not be immediately apparent to people outside the ED, Morris says. Then, she says, it is the ED manager's responsibility to "notify the internal stakeholders" as to what occurred. "There should be an internal incident reporting policy, and you would probably want to escalate the knowledge you have and participate in a root-cause analysis," Morris suggests.

Giuntoli says, "If the event happened in the ED, what we've seen is the root-cause analysis process involves the individual at the bedside and also the people who oversee that area." However, there is a point person in the organization who is the identified "owner" of how the facility does root-cause analyses, she says.