Health Care – Risk Management – Case Assignment A reviewable sentinel event may be self-reported or reported after notification from JCAHO and must include a root cause analysis and an action plan. The root cause analysis focuses on systems and processes to identify the factors causing a variation in performance and must be thorough, credible and acceptable. An action plan is acceptable if it gives changes to reduce risk, rationale and specifics on implementation and assessment. There are multiple civil and criminal legal implications of sentinel events. TQM and CQI can be significantly aided by reporting and root cause analysis to establish a quality risk management program due to the methodical, specific and national standards and resources made available through JCAHO.
¶ … sentinel event is reported to JCAHO through a root cause analysis and an action plan according to set timetables and procedures. In addition, a sentinel event can have numerous civil and criminal implications. Fortunately, through the methodical reporting and root cause analysis established by JCAHO, hospital administrators can develop highly effective risk management programs.
The Basics Of Sentinel Event Reporting
A reviewable sentinel event may be self-reported or reported after notification that JCAHO is aware of the event. Self-report uses a computerized form in the "Continuous Compliance Tools" subsection of the "Self-Report Sentinel Event" section on the "Joint Commission Connect" ™ intranet site (JCAHO, 2012, p. 13). The hospital must prepare a root cause analysis and action plan within 45 calendar days of the occurrence or awareness of the occurrence and must submit them to JCAHO within 45 calendar days of the known occurrence. If reviewability is determined more than 45 days after the known event, the hospital has 15 calendar days to submit the root cause analysis and action plan to JCAHO and if the hospital fails to submit them more than 45 calendar days after the due date, the failure may affect the hospital's accreditation (JCAHO, 2012, p. 9). If JCAHO determines that the root cause analysis and/or action plan are unacceptable, it will consult with the hospital and grant an additional 15 calendar days to bring those documents into compliance. If the hospital still fails to submit an acceptable root cause analysis and action plan and if JCAHO determines that the hospital did not make serious efforts to improve, accreditation may be affected (JCAHO, 2012, p. 16). If JCAHO determines that the root cause analysis and action plan are acceptable, it will so notify the hospital and assign an appropriate follow-up activity that the hospital will have 4 months to complete (JCAHO, 2012, p. 17). The hospital may request a JCAHO review of its response in writing and within at least 5 business days of either the self-report or of JCAHO's notification of its awareness of the reviewable sentinel event (JCAHO, 2012, p. 16).
The root cause analysis focuses on systems and processes to identify the factors causing a variation in performance. A root cause analysis moves from "special causes," which are intermittent and unpredictable causes not inherent in the process/system, to "common causes," which are inherent aspects of the process/system, and the analysis must be thorough, credible and acceptable. It is thorough if it determines all factors most directly associated with the event, analyzes the underlying systems/processes through "Why?" questions to find where redesign could reduce risk, inquires into all appropriate areas connected to the type of event, identifies the risk points and their possible contributions to the type of event, and determines potential effective improvements to reduce the chance of future events or determines that there are no opportunities for improvement. It is credible if it involves hospital leadership and staff most closely involved in the processes/systems being reviewed, is internally consistent and answers all obvious questions, explains all "not applicable" and "no problem" findings, and considers any relevant literature. It is acceptable if it is both thorough and credible, focuses on systems/processes instead of individuals, progresses from special causes to common causes, continuously digs deeper through progressive "Why?" questions, and provides possible changes that could reduce the likeliness of a similar event (JCAHO, 2012, pp. 10-11). An action plan is acceptable if it gives changes to reduce risk or gives a rationale for not adopting those changes, and if improvements are planned, states who is responsible for implementation, when the changes will occur and how effectiveness will be evaluated (JCAHO, 2012, p. 11).
b. The Legal Implications Of Sentinel Events
Aside from implications for accreditation, there are numerous legal implications arising from sentinel events. Since "sentinel event" encompasses "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" (JCAHO, 2012, p. 1), including but not limited to deaths (including suicides), sexual abuse/assault, abduction and serious surgical/radiological mistakes, the hospital and involved staff members could certainly be subject to civil suit (MacCourt & Bernstein, 2009). In conjunction with possible civil liability and depending on the terms of liability insurance, the hospital and/or staff may be required to timely report sentinel events to the insurer (MacCourt & Bernstein, 2009). Criminal liability is also an important factor to consider. Depending on federal/state/local laws, the hospital and involved staff members may be subject to criminal prosecution (MacCourt & Bernstein, 2009). Furthermore, depending on federal/state/local laws, the hospital and staff members may be required to report the incident to local authorities (MacCourt & Bernstein, 2009). Consequently, hospital policies regarding accreditation, civil law requirements and criminal law requirements must be thoroughly enumerated and impressed upon hospital staff.
c. TQM/CQI, Reporting And Analysis In Risk Management
Total Quality Management (TQM) is a comprehensive perspective that builds quality across an organization by systemic policies and practices through elements including but not limited to setting standards, creating strategies to close gaps in treatment, and using quality teams (Powell, 2008, p. 9). Continuous Quality Improvement consists of "systematic, data-guided activities designed to bring about immediate improvements in healthcare delivery in particular settings" (Powell, 2008, p. 7). Both TQM and CQI provide a hospital with the opportunities and tools to improve the quality of care. Due to a hospital's TQM and CQI, the occurrence of a sentinel event -- whether or not it is reviewable by JCAHO standards - should trigger a root cause analysis to identify the factors causing a variation in performance (Powell, 2008, pp. 72-3).
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