Alternatives for Sharing Sentinel Event-Related Information with The Joint Commission
The Sentinel Event Policy requires the organization to share its root cause analysis or comprehensive systematic analysis (RCA), plan of action (POA), and other sentinel event-related information with The Joint Commission. The organization is provided options for the method of sharing the information once the event is determined to be reviewable by the Office of Quality & Patient Safety (OQPS).
The methods of sharing the RCA are detailed below. The most frequently selected method is the Alternative 0, which has no fee.
Alternatively, if the organization has concerns about waivers of confidentiality protections as a result of sending the RCA 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 except the alternative 0 will result in a fee to the organization. Inquiries about the fee should be directed to The Joint Commission’s Pricing Unit at 630.792.5115.
Regardless of the method of sharing selected by the organization, a bibliography should be completed as part of the RCA/POA process. The bibliography should contain evidence-based references pertinent to the sentinel event which the organization referred to during the completion of the RCA and POA. The organization will be required to provide a copy of that bibliography to the Patient Safety Specialist (PSS) reviewing the organization’s RCA/POA.
Methods of sharing information include:
Alternative 0 (electronic submission of RCA and POA; Most frequently used method of sharing information with The OQPS Sentinel Event Unit - no fee.)Once the event is determined sentinel, the PSS will place the RCA/POA tool on your secure extranet site. (The organization accesses the RCA tool from their secured extranet site.) This tool is completed online and includes the RCA, POA and bibliography. It is submitted to the Joint Commission within 45 business days of the date the organization became aware of the event. If the reporting occurs after day 45, the organization has 15 business days to complete the RCA/POA tool electronically and submit to The Joint Commission. A follow up conference call will be scheduled and conducted after the RCA/POA is received by The Joint Commission to discuss the information with the PSS. 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.
Alternative 1 (In-person meeting between organizational representatives and a PSS occurring at the Joint Commission Central Headquarters.)
Alternative 1 permits the organization to schedule an appointment to personally bring the RCA, POA, bibliography and other sentinel event-related documents to The Joint Commission headquarters building for review by the Joint Commission PSS and then leave with all of these documents still in the organization's possession with the exception of the bibliography.
The Joint Commission staff will work with the organization to determine the 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 review of the organization’s Sentinel Event policy to verify that the organization’s definitions of reviewable sentinel events are consistent with the definitions established by The Joint Commission
- 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 RCA and related documents.
- Review of the associated POA.
- Closing discussion to summarize the conclusions reached by Joint Commission staff and determine next steps.
**Web Alternative 1: This method of sharing can also be performed via web-based video conferencing with a PSS who is located at The Joint Commission. The organization’s participants remain at the organization.
Alternative 2 (Same as Alternative 1 except the PSS travels to the organization to review the RCA and POA.)
Alternative 2 is exactly the same process as Alternative 1 but permits the organization to request an on-site review of the RCA and other sentinel event-related documents by the PSS on-site at the organization.
Upon receiving such a request, The Joint Commission will schedule a PSS visit to the organization. The PSS will review the RCA, POA and related documents and discuss the organization's process for responding to the occurrence of a sentinel event. No copy of the RCA will be retained by The Joint Commission. The PSS will require the organization to provide a copy of the bibliography to be retained by The Joint Commission.
Alternative 3 (Same as Alternative 1 however the RCA is verbally shared by the organization with the PSS - no documents pertaining to the RCA are viewed. The POA document and bibliography are shared with the PSS.)
Alternative 3 is performed either on site at the organization or at Joint Commission headquarters. The components of the meeting are similar to Alternative 1 or Alternative 2 however the RCA document is not viewed by the PSS. The contents of the RCA are verbally shared by the organization with the PSS. The POA and the bibliography documents are viewed by the PSS. The PSS will require the organization to provide a copy of the bibliography to be retained by The Joint Commission.
Upon receiving such a request, The Joint Commission will schedule a PSS visit to the organization. The RCA document will not be reviewed by the PSS. The POA detailing the organization's risk reduction strategy should be prepared as a separate document and will be reviewed by the PSS. The in-person review will specifically include:
- An opening discussion to review the purpose of the visit and the activities to be conducted.
- A review of the organization’s Sentinel Event policy to verify that the definitions of what is considered sentinel are consistent with the definitions established by The Joint Commission
- A presentation by the organization of its process for responding to a sentinel event.
- A structured discussion with the organization's leaders and staff regarding the results of the RCA.
- A review of relevant documents (e.g., selected policies and procedures).
- Review of the POA document resulting from the RCA.
- An exit discussion to summarize the conclusions reached by the PSS.
- No copy of the RCA will be requested or retained by The Joint Commission.
**Web Alternative 3: This method of sharing can also be performed via web-based video conferencing with a PSS who is located at The Joint Commission. The organization’s participants remain at the organization.
Alternative 4 (Onsite Announced Survey)
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 RCA 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 0, 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 RCA for the event under review.
- 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 that traces a patient’s care, treatment and services and the hospital management functions relevant to the sentinel event under review.
- An exit discussion to summarize the surveyor's findings.