Action taken by the Board of Directors of the Joint Commission has resulted in a refinement of the Sentinel Event Policy reporting process.

Currently, healthcare organizations may share with the Joint Commission information on a reportable sentinel event in one of three ways:

1. Submitting a copy of the root cause analysis and the related action plan and measurement system; or

2. Permitting on-site review of the root cause analysis and related documentation by a surveyor; or

3. Permitting a surveyor to conduct an on-site interview of key organization staff and a review of documentation limited to root cause analysis information

Subject to development of a few procedural considerations, a fourth option will be made available that addresses the legal concerns of losing evidentiary privilege in sharing sentinel event information with the Joint Commission. The new option is based on a recommendation by the Sentinel Events Legal Issues Task Force.

The fourth option is process-oriented. It involves a detailed on-site verbal interview by a surveyor. Surveyors will have access to otherwise discoverable factual information only, including discoverable portions of the medical record, the procedures in existence at the time of the event, and procedures now in use.

During the on-site review, questions may be posed to those representing the healthcare organization. These inquiries will not address causation or the deliberations that took place during the root cause analysis.

The Board also extended to 45 days the time permitted for completion of an acceptable root cause analysis and making it available to the Joint Commission.

As many members know, ASHRM was one of the first national organizations to bring attention to the risk exposures stemming from the Joint Commission Sentinel Event Policy. From the outset, ASHRM has participated in the Joint Commission Sentinel Event Legal Issues Task Force. It will continue to do so.

Once the procedural steps are finalized for the fourth option (on-site review protocol), ASHRM will provide detailed information to the membership. Along with information provided by local and healthcare association legal counsel, healthcare facilities and professionals will then be in a position to develop practical policies on sentinel events.

Should you have any questions in the interim, please contact ASHRM or Donna Nowakowski at the JCAHO Hotline at 1-630-792-3700.