Alternative 1 |Alternative 2 | Alternative 3| Alternative 4
The Sentinel Event Policy requests the organization to transmit its root cause analysis, action plan, and other sentinel event-related information to The Joint Commission electronically.
The Sentinel Event Policy provides that an organization which is either;
- voluntarily reporting a sentinel event, or
- responding to The Joint Commission's inquiry about a sentinel event,
is to then submit the related root cause analysis and action plan to the Joint Commission using an online RCA collection tool. The Joint Commission will not release the information to any external entity and will vigorously defend the confidentiality of the information, if necessary, in the courts.
Alternatively, if the organization has concerns about waivers of confidentiality protections as a result of sending the root cause analysis documents to The Joint Commission, the following alternative approaches to a review of the organization’s response to the sentinel event are acceptable. Any one of the four alternatives will result in a sufficient charge to the organization to cover the average direct costs of the visit. Inquiries about the fee should be directed to The Joint Commission’s Pricing Unit at 630/792-5115.
Alternative 1 permits the organization to schedule an appointment to personally bring the root cause analysis and other sentinel event-related documents to The Joint Commission headquarters building for review by Joint Commission staff and then leave with all of these documents still in the organization's possession.
An organization intending to visit The Joint Commission for review of the root cause analysis and related information should contact the Sentinel Event Hotline at (630) 792-3700 to plan for this session. The Joint Commission staff will work with the organization to determine the other relevant information that the organization should bring to the review session. The review session is generally scheduled for five hours and will include:
- An opening discussion to review the purpose of the visit and the activities to be conducted.
- A presentation by the organization of its process for responding to a sentinel event.
- A review of the specific sentinel event under review.
- Review of the root cause analysis and related documents.
- Review of the associated action plan.
- Closing discussion to summarize the conclusions reached by Joint Commission staff and determine next steps.
Alternative 2 permits the organization to request an on-site review of the root cause analysis and other sentinel event-related documents by a Joint Commission surveyor on-site at the organization.
Upon receiving such a request, The Joint Commission will schedule a surveyor visit to the organization. The surveyor will review the root cause analysis and related documents and interview appropriate organization staff to gain information about the organization's process for responding to the occurrence of a sentinel event. No copy of this root cause analysis will be retained by The Joint Commission.
Alternative 3 permits the organization to request an on-site visit by a Joint Commission surveyor to conduct interviews and review relevant documentation to obtain information about the process and findings of the root cause analysis and resulting action plan, without actually reviewing the root cause analysis documents.
Upon receiving such a request, The Joint Commission will schedule a surveyor visit to the organization. The surveyor will review the relevant documentation and interview appropriate staff regarding the organization's process for conducting a root cause analysis and the results of the specific root cause analysis in question. An action plan detailing the organization's risk reduction strategy should be prepared as a separate document and will be reviewed by the surveyor. The on-site review will specifically include:
- An opening discussion to review the purpose of the visit and the activities to be conducted.
- A presentation by the organization of its process for responding to a sentinel event.
- A series of structured interviews with the organization's leaders and staff involved in the root cause analysis process.
A review of relevant documents (e.g., selected policies and procedures).
- Review of the action plan resulting from the root cause analysis.
A tour of relevant areas of the organization.
- An exit discussion to summarize the conclusions reached by the surveyor.
- No copy of the root cause analysis will be requested or retained by the Joint Commission.
Alternative 4 permits the organization to request an on-site review of its process for responding to a sentinel event and the relevant policies and procedures preceding and following the organization's review of the specific event.
This Alternative was created in 1998 by the Board of Commissioners as an option to be used in those instances where the organization meets specified criteria respecting the risk of waiving legal protections for root cause analysis information shared with the Joint Commission. The chief executive officer of the organization electing this Alternative for reporting sentinel event-related information will be asked to sign an Affirmation statement indicating that he/she has, on behalf of the organization:
- Considered the relevant statutes, existing protective privileges, and case law in reaching the conclusion to proceed with Alternative 4.
- Considered Alternatives 1, 2, and 3 for sharing sentinel event-related information with the Joint Commission and has concluded that the use of any of these other alternatives may waive existing confidentiality protections for this information.
- Determined that the organization has completed a thorough and credible root cause analysis for the event under review.
Upon receiving a request for this Alternative, The Joint Commission will schedule a surveyor visit to the organization. The on-site review process will involve interviews with the organization leaders and staff, review of otherwise discoverable factual information about the sentinel event (including the medical record), and review of relevant documentation. It will specifically include:
- An opening discussion to review the purpose of the visit and the activities to be conducted.
- A presentation by the organization of its process for responding to a sentinel event.
- Structured interviews with the organization's leaders and staff to review policies and procedures preceding and following the organization's review of the specific sentinel event.
- A standards-based evaluation of the patient care and organization management functions relevant to the sentinel event under review.
- An exit discussion to summarize the surveyor's findings.
The Joint Commission may request additional information from the organization if its Accreditation Committee finds that the results of the on-site review under Alternative 4 are inconclusive in determining the acceptability of the organization's response to the sentinel event.