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JCAHO's fourth option allows on-site interviews
The ever-evolving sentinel event policy is gradually becoming more user-friendly. The policy is about to be changed so it is less threatening to risk managers who fear that complying with the policy would make potentially damaging information available to plaintiffs' attorneys.
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, is about to amend the sentinel event policy to address the possibility of losing evidentiary privilege when supplying sentinel event information, according to sources within the American Society for Healthcare Risk Manage ment (ASHRM). The change was recommended by the Sentinel Events Legal Issues Task Force, one of the subcommittees that involves members of ASHRM, the American Hospital Association, and other groups in guiding changes to the sentinel event policy.
Some procedural changes still are being worked out, but the Joint Commission has decided to create a fourth option for providing information on a reportable sentinel event. The new option will allow health care providers to supply information through a detailed, on-site interview with a Joint Commission surveyor. The surveyor will have access to only factual information, including discoverable portions of the medical record, the procedures in place when the sentinel event occurred, and current procedures at the facility. That information already was discoverable.
The surveyor may ask questions of the health care provider during the interview, but the questions will not address causation or the discussions that were part of the root cause analysis. The changes should eliminate most of the concern that the original sentinel event policy would force providers to include privileged information in the root cause analysis and then turn that over to the Joint Commission, a process that might eventually make much of the information discoverable.
The one-day on-site interview will cost the provider $2,300, says Janet McIntyre, spokes woman for the Joint Commission.
An on-site interview will be only one of four options available to providers. The health care provider reporting a sentinel event still can submit a copy of the root cause analysis and a planned response, or the provider can permit an on-site review of that analysis and plan.
As a third option, the provider can permit a Joint Commission surveyor to conduct an on-site interview of key organization staff and review documentation related to the root cause analysis.
The new fourth option is different in that it does not include a review of root cause analysis information, possibly making it a better choice if the risk manager is concerned about the evidentiary privilege of information contained in the analysis. The root cause analysis still is required in response to a sentinel event.
The Joint Commission also has extended the time allowed for a root cause analysis from 30 days to 45 days.