The Joint Commission on Accreditation of Healthcare Organizations late last week made several changes to its protocols on sentinel event policy.
Taken together, the changes have the effect of watering down the reporting requirements.
The measures respond to the widespread fear that by submitting reports on patient-care accidents that lead to death or severe harm to a patient, providers will expose themselves to potential legal liability in some states.
To remedy this, the Joint Commission arranged for language to be inserted in the Patient Protection Act of 1998, sponsored by Rep. J. Dennis Hastert (R-Ill.), that would extend peer-review protections to information shared with an accreditor. The legislation was passed by the House on Friday (See story, above).
At its meeting on July 17, the board of commissioners extended the time for completing the root-cause analysis of the adverse event to 45 days from 30 days.
Where previously a hospital that refused to share information on a sentinel event would have been assigned preliminary nonaccreditation, now it will be assigned accreditation watch. This is a diminution in the penalty for noncompliance.
The board also refined the protocols for sentinel event response into four options:
The simplest: Do a root-cause analysis and an action plan and mail them to the Joint Commission.
If you're concerned about confidentiality, write a root-cause analysis and the Joint Commission will review it on site.
If you're afraid to show the analysis document to the Joint Commission, the agency will assess the information from the analysis without looking at it.
A new option, now a year-long test, is for institutions that are constrained from waiving certain legal protections. The hospital could describe the event and explain how it does a root-cause analysis and how it changed its systems and procedures to avoid a similar accident.