The JCAHO and Sentinel Events Assignment Instructions
The Joint Commission has established polices regarding the reporting of sentinel events by health care organizations. Visit The Joint Commission’s website and review the Sentinel Event Policy and Procedures by Accreditation and/or Certification Program for two different types of organizations (e.g. ambulatory health care, long-term health care, hospitals, etc.).
Prepare a composition that discusses the following:
- The importance of sentinel event reporting
- General requirements of The Joint Commission’s Sentinel Event policy
- The role of The Joint Commission in ensuring patient safety
- The process of conducting a root cause analysis
- Comparisons and contrasts on some of the organization-specific sentinel event examples that are subject to review by the Joint Commission between two different healthcare organizations (e.g. differences between an ambulatory health care and a hospital).
- The role and responsibilities of the risk management function in ensuring organizational compliance with The Joint Commission’s Sentinel Event policy
The Joint Commission
The Joint Commission performs essential responsibilities in the health sector. The commission ensures that the public receives the best health care quality. To support this mandate, the commission performs reviews of the activities of the hospital especially in response to sentinel events. This happens in the process of accreditation that entails for-cause surveys, as appropriate, full accreditation surveys, and random validation surveys (Natarajan, 2006). According to Natarajan (2006), a sentinel event is a startling incidence, which may involve serious psychological or physical injury, and to the worst extent, death. In the event that the patient suffers serious injury, then the situation should indicate a victim’s loss of function or even limb. The reason why such events bear the name “sentinel” is because they demand immediate analysis and quick response (Moore, 2008). Therefore, the joint commission continues collaborating with various stakeholders to ensure that the health care sector offers the safest and most effective care to patients.
The importance of sentinel event reporting
Sentinel event reporting has a lot of significance. It necessitates root cause analysis (Moore, 2008). This entails identification of causal or fundamental factors, which underlie the performance variation. Therefore, reporting gives details of probable occurrence or even actual occurrence of a given sentinel event. The main focus of the root cause analysis is mostly on the processes and systems and never on the individual performance (Natarajan, 2006). The report gives details of common causes in regards to the organizational processes as well as systems. It, also, gives details of special causes in regards clinical processes. Reporting is, also, essential because it leads to the development of an action plan. The processes involved in the analysis of the root cause lead to the establishment of an action plan. An action plan is essential in the sense that it identifies the approaches, which the organization should implement in order to decrease the likely occurrence of similar events some other time in the future (Ladema & Jorm, 2008). Therefore the report should give details regarding strategies, time lines, pilot testing, oversight and implementation that should comprise the action plan (Moore, 2008).
The sentinel event reporting is, also, essential because it gives details of the survey process (Ladema & Jorm, 2008). In most cases, the Joint Commission endeavors to assess the compliance of an organization whenever it organizes for an accreditation survey. During the process, the Joint Commission only requires the surveyors to avoid addressing sentinel events that are not yet known. Reporting, also, enables the public to know the progress of the organization in terms of minimizing and ending sentinel events (Ladema & Jorm, 2008). By collaborating with the joint commission, it becomes easy to understand the manner in which such events happen, and what should happen to eradicate such events in the future. Reporting an event as early it happens provides an ample opportunity to engage the staff of the Joint Commission in consultations. These consultations usually happen during the stage of analyzing the root cause and development of an action plan. Sentinel event reporting, also, provides for addition of the lesson learned during the event to be included in the sentinel event database of the Joint Commission (Moore, 2008).
General requirements of The Joint Commission’s Sentinel Event policy
It is worth noting that the Sentinel Event Policy of the Joint Commission has various requirements. Sentinel policy requires every accredited organization to provide a definition of the sentinel event (Hellings & Schrooten, 2007). This provides assistance especially regarding mechanisms of identification, reporting and management of such events. In such cases, the definition, which an organization provides should include only events whose review is provided for in the Sentinel Event Policy. The Sentinel Event Policy, also, requires that, during the occurrence of the sentinel event, the accredited organization should be prompt in conducting an analysis to establish the root cause (Hellings & Schrooten, 2007). It should, also, be prompt in developing an action plan, and implement essential improvements in order to reduce the risk. It should, also, be consistent in monitoring the effectiveness of all the essential improvements. The Sentinel Event Policy requires that reporting an event should happen through the system for event reporting, and it should happen up to the corporate level (Moore, 2008). It, also, requires that a credible analysis of the root cause of the event should happen through Root Cause Meetings. These meetings should happen within fourteen days of the occurrence of the event (Moore, 2008). All the attendees of such meetings should comprise of groups coming from different disciplines.
The role of The Joint Commission in ensuring patient safety
The Joint Commission ensures the safety of the patients through a number of ways. First, it has a mandate to practice continuous improvement of health care for the benefit of the public. It conducts an assessment of organizations, which provide health care and motivates them to maintain high quality, effective and safe health care at all times (Natarajan, 2006). The Joint Commission, also, encourages the physicians to engage in quality health care and patient safety. This is because their skills, knowledge as well as experiences are significant for positive health care and experiences of the patients (Natarajan, 2006). The Joint Commission, also, guarantees patient safety by enhancing and encouraging the involvement of physicians in accreditation. In the same respect, the Joint Commission, also, ensures that nurses adhere to standards, rules and laws in order to guarantee desirable patient safety during their practice (Hellings & Schrooten, 2007). The Joint Commission, also, encourages and motivates patients to ensure their own safety.
It is essential to note that there are various steps involved in conducting a root cause analysis. The first step entails gathering facts where the facilitator conducts interviews (Hellings & Schrooten, 2007). Supporting materials are essential during the next step. In this case, the facilitator should establish a timeline of the incident. The third essential step involves putting the team together (Root Cause Analysis Team) where each individual on the team should receive equal treatment (Natarajan, 2006). The fourth step involves laying ground rules that should guide the team. The team then should understand whatever transpired and establish the root cause. It should then establish education plan and assess the efficiency of actions. It should then report activities and findings to the oversight committee in charge of quality.
In conclusion, a sentinel event is a startling incidence, which may involve serious psychological or physical injury, and to the worst extent, death. Sentinel event reporting has a lot of significance. It necessitates root cause analysis. This entails identification of causal or fundamental factors, which underlie the performance variation. It conducts an assessment of organizations, which provide health care and motivates them to maintain high quality, effective and safe health care at all times. It is essential to note that there are various steps involved in conducting a root cause analysis. They include gathering facts, supporting materials, putting the team together, laying ground rules, and reporting activities.
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