Options for Reporting of Healthcare Sentinel Events to The Joint Commission

PEER REVIEW STATUTES: PROTECTING YOUR INTERESTS

Reprinted with permission from:

The Joint Commission Advisor for Behavioral Health Care Providers, June 1999, 3(6), pp 1-4. While this article focuses on behavioral health, the comments are fully applicable to health care in general.

. . 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 alternative approaches to review of the organization's response to the sentinel event are acceptable.

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 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. The latter serves 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 organization will be assessed a charge sufficient to cover the average direct costs of the visit."