Board Votes To Increase Time Frame For Submitting Root Cause Analysis

At its July 17-18 meeting, the Joint Commission's Board of Commissioners approved a modification to the Sentinel Event Policy and Procedures which allows accredited organizations 45 days from the event, or of becoming aware of the event, to complete an acceptable root cause analysis before being at risk of being placed on Accreditation Watch. This action takes effect immediately. Previously, organizations were required to submit an acceptable root cause analysis within 30 days of the event or of becoming aware of the event. The 45-day time frame applies whether or not the organization chooses to self report the sentinel event.

Protocols Established For On-site Review Of Response To A Sentinel Event

The Board of Commissioners approved two survey protocols for the conduct of structured, on-site interviews of key organization staff and the review of relevant documentation in follow-up to a sentinel event that qualifies for review by the Joint Commission. The board first approved a 12-month pilot test of a protocol developed by the Sentinel Event Legal Issues Task Force which will focus on the organization's sentinel event review process, the relevant policies and procedures preceding and following the organization's review of the sentinel event, and the implementation thereof. This protocol will be used in those instances where the organization meets specified criteria respecting the risk of waiving legal protection for root cause analysis information shared with the Joint Commission. These criteria will be developed in the coming weeks by the Accreditation Committee in conjunction with the Sentinel Event Legal Issues Task Force. The second protocol will permit the direct assessment of root cause analysis information without explicit review of the underlying document. This protocol is immediately available for use.

Board Approves Change To Policy And Procedures

The Board of Commissioners also approved a change to the Sentinel Event Policy and Procedures relating to an organization that refuses to permit the Joint Commission to review its response to a sentinel event by any of the available options. Effective immediately, an organization that refuses to permit review of its response to a sentinel event either through on-site review or by submitting documentation to the Joint Commission, will be placed on Accreditation Watch. Continued refusal to permit review could lead to eventual loss of accreditation.