Joint Commission addresses confidentiality

Contractual methods may protect your records

Confidentiality concerns regarding sentinel events can be addressed in part by making the Joint Commission on the Accreditation of Healthcare Organizations a kind of partner in your health care organization, according to newly released advice from the group.

The Joint Commission released the advice as part of a "Dear Colleague Letter" dated October 23, 1998. Such letters are the Joint Commission’s official way of communicating new developments and recommendations to providers. The most recent letter outlines some of the latest changes to the controversial sentinel event policy. (For a report on those changes, see Healthcare Risk Management, December 1998, pp. 145-149.)

New ways to protect information

But in addition to the policy changes, the Joint Commission offers contractual methods that might improve your protection of confidential information in the sentinel event system. The options were developed with the assistance of the sentinel event legal issues task force, which includes representatives from the American Society for Healthcare Risk Management. These are the suggestions:

• Identify, through written agreement, the Joint Commission as a participating entity in the organization’s peer review or quality improvement activities.

• Appoint the Joint Commission to the organization’s peer review or quality improvement committee.

Using one or both of those options should clarify that "the Joint Commission is not an external third party in the limited context of an intensive assessment of a sentinel event and, therefore, no waiver of confidentiality protections has occurred by sharing sentinel event-related information with the Joint Commission," the letter states. The Joint Commission says these options, especially the first one, should help you comply with the sentinel event policy without giving up confidentiality.

The Joint Commission also used the letter to offer clarifications of some issues that have caused confusion recently regarding sentinel events. Here are some of the clarifications:

• An on-site visit to discuss the root cause analysis or otherwise hear of the provider’s analysis will cost $2,300. But a "for cause" survey, conducted when the Joint Commission thinks there is an ongoing threat to patient safety or a significant noncompliance with standards, will cost $3,500.

• Only 60% of initial root cause analysis submissions have met the established "thorough and credible" criteria. The Joint Commission urges providers to seek help from the commission before starting the review process. "We will respond to generic or what if’ questions," the letter states.

• The Joint Commission says it has no intention of disclosing information about sentinel events during the review process. If someone asks the Joint Commission about the accreditation status of an organization that has experienced a reviewable sentinel event, the organiza- tion’s accreditation status will be reported in the usual manner without making reference to the sentinel event, the letter states.

"If the inquirer specifically references the sentinel event, the Joint Commission will acknowledge that it is aware of the event and is working with the organization through the sentinel event review process," the letter says.

(Healthcare Risk Management’s experience with the Joint Commission supports that position. When HRM asks about known sentinel events, the Joint Commission representative acknowledges that he or she knows of the event but says little beyond that.)

The letter goes on to stress that the Joint Commission "scrupulously maintains the confidentiality of organization-specific sentinel event-related information in its possession. Sensitive documents are eventually returned to the organization or destroyed."

However, information about or resulting from a "for cause" survey will be disclosed to the public on request.