New sentinel policy encourages self-reporting

Confidentiality not far enough, some say

Beginning April 1, you will be able to self-report sentinel events and be confident that your facility’s accreditation status will remain untarnished as long as you followed prescribed steps. Under a new limited confidentiality provision, the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, will not disclose sentinel events if it receives an inquiry about an organization’s accreditation status during a 30-day root-cause analysis period. However, if someone calls the Joint Commission and asks about a specific event, the agency would verify that the event took place and that an investigation is ongoing at that facility.

Hanging out dirty laundry

"Prior to this revision," says Robert Pollack, MD, director of Professional Quality Analysts in Casselberry, FL, "when a hospital reported an event, right away it became public knowledge that the facility was on accreditation watch. That was a tremendous disincentive to self-reporting. No one wants to hang out dirty laundry."

Now the Joint Commission says you have five days to report an event, followed by 30 days to do a full investigation with a corrective action plan. Six months later the agency will come back and see what you’ve done. During that time, the Joint Commission will not make public the nature of the event or investigation.

The limited confidentiality framework of the Joint Commission’s revised sentinel event policy is meant to encourage more self-reporting of sentinel events and stimulate thorough examinations of their root causes. The approach parallels the airline industry’s approach, as well as that of the American Medical Association’s National Patient Safety Foundation, which provides protected venues for self-reporting errors. (See related article on root-cause analyses, p. 55.)

In Pollack’s opinion, the Joint Commission hasn’t gone far enough toward confidentiality. You can’t reveal self-reported information even to this limited extent and expect facilities to continue telling on themselves, he says. "It just won’t work. It’s a disincentive to self-reporting. Honesty may be the best policy, but not when you’re looking into people’s wallets."

From the information collected, the agency will create a database of recurrent sentinel events and catalog the most common underlying causes for these events. Information will be regularly disseminated to health care organizations and other interested parties in order to reduce the frequency of medical errors.

"Facilities should be doing that anyway internally," says Pollack. "Hospitals should have in place good sentinel analysis programs that profile what takes place where."

Voluntary, like in the Army, say some

Self-reporting sentinel events is voluntary, but an organization that chooses not to report within five business days of an occurrence risks being placed on accreditation watch if the event later becomes known by other means. Similarly, if you fail to perform and submit an appropriate root-cause analysis within 30 days of the event, you waive limited confidentiality protection, although the content of individual root-cause analyses is not itself disclosable under any circumstances. If you waive your limited confidentiality protections, you become subject to immediate follow-up on-site evaluations, each costing $3,500.

Regardless of whether an organization self-reports or is placed on accreditation watch, if an adequate root-cause analysis is not performed and appropriate actions implemented, a change in accreditation status can result, including loss of accreditation. In addition, each sentinel event evaluated will be reviewed at the next full accreditation survey, and the review will focus on how effectively the organization is continuing its risk-reduction activities.

Suggested reading

Spath P. Investigating Sentinel Events: How to Find and Resolve Root Causes. Forest Grove, OR: Brown-Spath & Associates; 1997.

For ordering information, contact Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116; (503) 357-9185;;