Legal reasons to offer options for reviewing sentinel events

The following are the newly revised options for how the Joint Commission on the Accreditation of Healthcare Organizations may review a provider’s documentation concerning a sentinel event:

Alternatively, if the organization has concerns about increased risk of legal exposure as a result of sending the root cause analysis documents to the Joint Commission, the following procedures for review of the organization’s response to the sentinel event are available:

1. Review of root cause analysis documents brought to Joint Commission headquarters by organization staff, then taken back to the organization on the same day.

2. An on-site visit by a specially trained surveyor to review the root cause analysis and action plan. The organization will be assessed a charge sufficient to cover the average direct costs of the visit.

3. An on-site visit by a specially trained surveyor to review the root cause analysis process and findings, without directly viewing the root cause analysis documents, through a series of interviews and review of relevant documentation. For purposes of this review activity, relevant documentation includes, at a minimum, any documentation relevant to the organization’s process for responding to sentinel events, and the action plan resulting from the analysis of the subject sentinel event (to serve as the basis for appropriate follow-up activity). The organization will be assessed a charge sufficient to cover the average direct costs of the visit.

4. Where the organization affirms that it meets specified criteria respecting the risk of waiving legal protection for root cause analysis information shared with the Joint Commission, an on-site visit by a specially trained surveyor to conduct interviews and review relevant documentation to obtain information about:

• the process the organization uses in responding to sentinel events;

• the relevant policies and procedures preceding and following the organization’s review of the specific event, and the implementation thereof, sufficient to permit inferences about the adequacy of the organization’s response to the sentinel event. The organization will be assessed a charge sufficient to cover the average direct costs of the visit.

A request for review of an organization’s response to a sentinel event using any of these alternative approaches must be received by the Joint Commission at least 15 days prior to the due date for the root cause analysis and action plan.