JCAHO lightens its touch

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Some say the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has been heavy-handed in dealing with sentinel events in past years. In a recent statement, president Dennis S. O’Leary said the agency is attempting to address adverse occurrences fairly and reasonably. "On the surface, each of these events seems like it was just an accident — a special cause variation," he said. "But most special cause variations are rooted in common cause variations. In the future, our analytic capabilities are going to permit us to knowledgeably drill down from an isolated event to understand the cause-and-effect relationships between process and outcome so that processes may be altered or improved to avoid similar future sentinel events."

The Joint Commission defines a sentinel event as any unexpected occurrence involving death, serious physical or psychological injury, or the significant chance of a serious adverse outcome. Root-cause analyses are required of accredited organizations any time a sentinel event occurs. While the immediate cause of most sentinel events is human error, the analysis is expected to dig down to underlying systems and processes that can be altered to reduce the likelihood of future error.

The new policy states that if an accredited organization reports a sentinel event within five business days of its occurrence, or of becoming aware of its occurrence, the facility will not be placed on accreditation watch, which allows public disclosability. Organizations that self-report will not be subject to an immediate on-site review unless it is determined that there is a potential threat to patient safety. Rather, the organization will be given 30 days to complete a thorough root-cause analysis, submit it to the Joint Commission, and implement appropriate actions. Joint Commission follow-up will then occur within the ensuing six months.

"We must encourage and even reward the reporting of errors in order to make meaningful strides in medical error reduction," said O’Leary. "The Joint Commission is committed to removing barriers to better understanding and reducing the risk of sentinel events."

Under the current policy (in effect until April 1), when a sentinel event becomes known to the Joint Commission, an on-site evaluation is usually conducted. The organization must submit to the Joint Commission a complete and credible root-cause analysis and an action plan. While the root-cause analysis is being prepared, the organization retains its accreditation status, but is placed on accreditation watch if there seems to be a reasonable potential for reducing the likelihood of similar events in the future. After the Joint Commission has received an acceptable root-cause analysis, follow-up occurs either through a written progress report or an on-site visit to assess the implementation of systems and process improvements identified through the analysis.

Reducing risk through accreditation

"As good as health care is in America, sentinel events happen in health care organizations every day," adds O’Leary. "The challenge is to make accreditation an increasingly effective risk- reduction process through actively engaging accredited organizations in these critical problem-solving activities."

One consultant voices a concern that information housed at the Joint Commission may not be protected from discovery by plaintiffs’ attorneys in the case of a lawsuit. The Joint Commission says it’s working with the National Health Lawyers Association in Washington, DC, in a state-by-state analysis of peer review protections. Protection of peer review documents is defined at the state level. Therefore, if there are loopholes that might allow an attorney or anyone else, such as a consumer group, to get access to documentation housed at the Joint Commission, the issue has to be addressed by the state involved.

"The legal aspects of protecting root-cause documentation from discovery are interesting," says Robert J. Latino, vice president of strategic development for Reliability Center, an engineering consulting firm in Hopewell, VA. "We’ve dealt with this paradox for years. I can relate our experience from the industrial setting and dealing with OSHA and EPA. The fact of the matter is that nothing is protected from discovery. You can stall with ‘orders to protect’ proprietary information from becoming public in the courts, but when a judge issues an ‘order to compel,’ if you do not produce the document you are in contempt and face imprisonment."