JCAHO fine-tunes sentinel event policy terms

Clarifications added to the sentinel event policy may not make it any more popular with risk managers, but they may at least help you understand what the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, expects from you.

The clarifications were added to the "Sentinel Event Policies and Procedures" on June 15, 1999. Joint Commission spokeswoman Janet McIntyre tells Healthcare Risk Management that the changes were intended to clear up some of the confusion that has plagued the sentinel event policy since it was first introduced. The policy has been changed many times since its inception, but McIntyre says the most recent alterations do not change any of its basic provisions. Rather they only clarify what the Joint Commission intended all along, she says.

One of the most important clarifications concerns how the Joint Commission determines whether a root cause analysis measures up to expectations. The root cause analysis, an in-depth internal investigation required after a sentinel event, must meet the Joint Commission’s standards or the provider will not be considered to have complied with the sentinel event policy. To help meet those standards, the Joint Commission added clarifications of several key definitions.

According to the recent clarifications, a root cause analysis will be considered acceptable if it has the following characteristics:

• The analysis focuses primarily on systems and processes, not individual performance.

• The analysis progresses from special causes in clinical processes to common causes in organizational processes.

• The analysis repeatedly digs deeper by asking "Why?" Then, when answered, "Why?" again, and so on.

• The analysis identifies changes that could be made in systems and processes — either through redesign or development of new systems or processes — to reduce the risk of such events occurring in the future.

• The analysis is thorough and credible.

Then the clarifications go on to define what makes a root cause analysis thorough and credible. To be "thorough," the root cause analysis must include:

• a determination of the human and other factors most directly associated with the sentinel event, and the process(es) and systems related to its occurrence;

• analysis of the underlying systems and processes through a series of "why?" questions to determine where redesign might reduce risk;

• inquiry into all areas appropriate to the specific type of event as described in the current edition of "Minimum Scope of Root Cause Analysis for Specific Types of Sentinel Events"

• identification of risk points and their potential contributions to this type of event;

• a determination of potential improvement in processes or systems that would tend to decrease the likelihood of such events in the future, or a determination, after analysis, that no such improve ment opportunities exist.

To be credible, the root cause analysis must:

• include participation by the leadership of the organization and by the individuals most closely involved in the processes and systems under review;

• be internally consistent, i.e., not contradict itself or leave obvious questions unanswered;

• provide an explanation for all findings of "not applicable" or "no problem"

• consider any relevant literature.

In addition, the Joint Commission provides clarification on what makes an action plan acceptable. An acceptable action plan:

• identifies changes that can be implemented to reduce risk or formulates a rationale for not undertaking such changes;

• identifies who is responsible for implementing improvement actions, when the actions will be implemented (including any pilot testing), and how the actions’ effectiveness will be evaluated.

The Joint Commission provides some reassurance to risk managers by stating, "All root cause analyses and action plans will be considered and treated as confidential by the Joint Commission."

The newly revised policies and procedures also offer this more detailed definition of accreditation watch status: "Accreditation watch is an attribute of an organization’s Joint Commission accreditation status that publicly acknowledges the collaborative efforts by the health care organization and the Joint Commission to understand the factors underlying a sentinel event and to implement appropriate changes to reduce the risk of such events in the future.

"A health care organization is placed on accreditation watch when a reviewable sentinel event has occurred and has come to the Joint Commission’s attention, and a thorough and credible root cause analysis of the sentinel event and action plan have not been completed within the specified time frame. Although accreditation watch status is not an official accreditation category, it can be publicly disclosed by the Joint Commission."

The other new additions address the Joint Com mission’s expectations of providers following a sentinel event. Here are the new standards, along with the Joint Commission’s explanations:

o New or modified processes are designed well. When processes, functions, or services are designed well, they draw on a variety of information sources. Good process design is consistent with the organization’s mission, vision, values, goals and objectives, and plans; meets the needs of individuals served, staff, and others; is clinically sound and current (for instance, use of practice guidelines, information from relevant literature, and clinical standards); is consistent with sound business practices; incorporates available information from other organizations about the occurrence of sentinel events to reduce the risk of similar sentinel events; and incorporates the results of performance-improvement activities. The organization incorporates information related to these elements, when available and relevant, in the design or redesign of processes, functions, or services.

o The organization collects data to monitor the performance of processes that involve risks or may result in sentinel events. Organizations select processes that are known to be high-risk, high-volume, problem-prone areas related to the care and services provided. This information is correlated with the listing of frequently occurring sentinel events published by the Joint Commis sion, the organization’s risk-management data, or information about problem-prone processes generated by field-specific or professional organizations. Organizations select performance measures for processes that are known to jeopardize the safety of the individuals served or associated with sentinel events in similar health care organizations.

o Undesirable patterns or trends in performance and sentinel events are intensively analyzed. When the organization detects or suspects significant undesirable performance or variation, it initiates intense analysis to determine where best to focus changes for improvement. The organization initiates intense analysis when the comparisons show that levels of performance, patterns, or trends vary significantly and undesirably from those expected; performance varies significantly and undesirably from that of other organizations; performance varies significantly and undesirably from recognized standards; or when a sentinel event has occurred. When monitoring performance of specific clinical processes, certain events always elicit intense analysis. Based on the scope of care or services provided, intense analysis is performed for confirmed transfusion reactions, significant adverse drug reactions, and significant medication errors. Intense analysis also should occur for topics chosen by leaders as performance-improvement priorities or when undesirable var iation occurs that changes the priorities. Intense analysis involves studying a process to learn in greater detail about how it is performed or how it operates.