The JCAHO’s Sentinel Event Policy requests a hospital voluntarily reporting a sentinel event to transmit it along with a root cause analysis, action plan and any other sentinel event-related information via an online form. Causal factors in an RCA should be analyzed with an emphasis on systems and processes rather than on the actions of individuals. Action plan suggests a proposal for potential improvements that would lead to decrease of the likelihood of similar sentinel events in the future.
The JCAHO vouchsafes the confidentiality of these reports. Alternatively, members of the hospital can take the relevant documents personally to the JCAHO headquarters at Oakbrook Terrace, Illinois or to the branch at Washington, D. C. Also, it is also possible to request the JCAHO’s staff to visit the hospital and review the relevant documents, or conduct interviews and investigate the sentinel event for themselves (Joint Commission). The JCAHO is a private sector organization which runs accreditation programs for a fee to interested hospitals.
Currently the Joint Commission accredits over 17,000 hospitals and other healthcare organizations in the U. S. A hospital that has the Joint Commission’s accreditation is considered to be of Medicare standards. Accredited organizations are strongly encouraged, although it is not mandatory, to report all sentinel events happening in their premises to the Joint Commission. Upon review of the accredited facility’s report, the JCAHO assesses the organization’s accredited status, and marks the organization for a follow-up after a period of six months.
If a hospital fails to complete an adequate root cause analysis and draft an action plan, it could be placed on “accreditation watch,” a status which may or may not be disclosed publicly. The JCAHO assists its member organizations to come up with a better root cause analysis and implement the appropriate action plans in a rigorous manner. The JCAHO’s central database disseminates information about sentinel events to all the hospitals in its network.