Calling the hospital industry's bluff, the Joint Commission has revised its controversial self-reporting policy to address hospitals' complaint that the policy could expose them to more malpractice lawsuits.
Under the revised policy, hospitals that want to self-report "sentinel events," or adverse patient incidents, to the Joint Commission on Accreditation of Healthcare Organizations can opt to have its surveyors visit their facilities rather than sending records of incidents to the JCAHO.
The JCAHO's board revised the policy at its April 24 meeting. The new option will be available to self-reporting hospitals starting July 1.
Despite the revision, the board stood by its self-reporting policy, which went into effect April 1. Under the policy, hospitals that turn themselves in to the Joint Commission after sentinel events won't get placed on its "accreditation watch" list, which makes hospitals at which such events have occurred publicly identifiable.
The board adopted the policy in an effort to get more hospitals to report problems, so it can compile a database to identify common problems that could be remedied with common solutions (March 2, p. 60).
But hospitals contended that if they turned themselves in to the Joint Commission and supplied it with a written report, called a "root-cause analysis," on the sentinel event, malpractice attorneys could obtain those materials.
In fact, the American Hospital Association, which has seven seats on the JCAHO's board, advised hospitals not to send in sentinel-event reports if they're not sure they won't be forced to turn them over to lawyers (April 13, p. 12).
Some observers, however, believe the malpractice fears are a smoke screen hiding the fact that some hospitals simply don't want to voluntarily report problems to the JCAHO.
Taking those fears at face value, the JCAHO board decided hospitals can have special surveyors come out for a site visit, but the hospitals have to pay for it.
For $2,300, the surveyors will read and verify that the analysis has been done correctly and gather information to add to the JCAHO's database. The board said this is an interim measure until it comes up with a better solution.
"If an organization declines to share any information regarding a sentinel event with the Joint Commission, the organization will be placed on accreditation watch and, ultimately, risks the loss of accreditation," the Joint Commission said.
The board also refined the definition of what kinds of events should be reported to the Joint Commission. Hospitals had complained that the definition was too broad.
The board also authorized one of its task forces to pursue federal legislation to protect the submitted reports under the peer-review principle. The task force is drafting model state legislation, too.
The Joint Commission says it wants to work with state hospital associations and other interested parties to find ways to close "identified gaps in confidentiality protection which remain unresolved."