The Joint Commission on Accreditation of Healthcare Organizations has altered its policy on sentinel events to encourage self-reporting of medical errors by hospitals. But critics blasted the change as yet another step back from public accountability.
The change, effective April 1, will reduce the application of a controversial JCAHO program called accreditation watch. That means in many cases the occurrence of a sentinel event no longer will be made public by the JCAHO.
A sentinel event is an unexpected patient death, serious physical or psychological injury to a patient, or the risk of such. Under existing policy, on learning of a sentinel event, the Joint Commission places the hospital on accreditation watch, a special status indicating the event is not consistent with the hospital's accreditation.
Under the Joint Commission's guidance, the hospital is required to identify the systemic failures that allowed the error to occur through a formal process known as root-cause analysis and then to reform procedures accordingly. Joint Commission surveyors visit the hospital to check on the situation.
During this process, the Joint Commission will disclose upon request that the hospital has experienced a sentinel event and has been placed on accreditation watch. The hospital maintains full accreditation during this period.
From October 1996, when the policy was implemented, to December 1997, 35 healthcare organizations were placed on accreditation watch. Of those, 31 successfully completed the process and were removed from the list.
As of April 1, however, any hospital that voluntarily reports a sentinel event to the Joint Commission within five days will not be placed on accreditation watch and will not be subject to immediate on-site review. The hospital will have 30 days to complete a root-cause analysis to the satisfaction of the Joint Commission. Failure means the hospital will end up on accreditation watch.
The new policy is meant to encourage self-reporting of accidents by hospitals. The accreditation-watch policy drafted in October 1996 was intended to do the same, although it didn't work out that way.
"Initially, you got placed on conditional accreditation, then that was changed to accreditation watch, all of which were perceived by the field as being punitive," said Dennis Barry, a member of the JCAHO board of commissioners and president of Moses Cone Health System in Greensboro, N.C.
Critics consider the JCAHO's latest move a step back from public accountability and are skeptical the hospital industry can be trusted to regulate itself outside public view.
Sidney Wolfe, M.D., director of Public Citizen's Health Research Group in Washington, said: "I suspect the only plausible explanation for this is they got lots of complaints from hospitals, who didn't want (sentinel events) to be made public and didn't like that someone was going to come in and look over their shoulder."
Added Claudia Schlosberg, a critic of private accreditation agencies, who works for the National Health Law Program in Washington: "The whole accreditation-watch program was a good marketing tool. It was a little too aggressive; now they scaled it back. It's fairly typical of how the Joint Commission operates."
Barry, who is one of seven JCAHO board members representing the American Hospital Association, said the policy was in fact changed after numerous complaints from the hospital industry. "There has been a lot of unhappiness, not only out in the field but also in the Joint Commission, too. It was clear the policy wasn't working as well as we wanted it to," he said.
The 28-member JCAHO board passed the change unanimously at its Nov. 7 meeting.
Paul Schyve, M.D., a senior vice president at the Joint Commission, said the issue wasn't what failed to work; the issue was what could be improved.
"From the beginning, the goal was to try to identify ways in which the risk could be reduced for patients," Schyve said. Over time, that thinking evolved.
Now the idea is to provide incentives to organizations to report these events so the JCAHO can develop an epidemiological database to answer such questions as: What types of sentinel events occur? How often do they occur? What are the findings when organizations do root-cause analysis of these events? What actions have they taken to prevent them in the future?
Schyve likened the confidentiality question to that between lawyer and client or priest and parishioner. "While in a specific case somebody might wish they knew (about the sentinel event), all of us benefit in the long term by the positive effect of having healthcare organizations not be defensive about looking at these things," he said.
The absence of the accreditation watch label is an incentive for self-reporting, Schyve said.
Wolfe isn't convinced: "They are much more concerned about pleasing the customers -- the hospitals -- than protecting the public and letting the public know about it," he said.
Barry responded that collection of information on sentinel events and root-cause analyses are "far more important than whether it is or isn't reported from the public point of view.
"If we want good work on what is causing sentinel events, then we are going to have to deal with this on a collaborative basis," he said. "If the field feels threatened by this, and it does harm them in some way, then I don't think we've created the right kind of envirnonment to address these issues."