Taking your Sentinel Events & Concerns to TJC

Taking your Sentinel Events & Concerns to TJC Balancing Joint Commission Requirements & Facility Specific Improvements Content Development: Susan McCammon, RHIA/CPHRM Presenters: Divya Reddy, MPH Stacy Collier, RN KershawHealth – Camden, SC

How TJC can find out about your Sentinel Event • Self Report (optional) • During on site Survey • Media • Public (complaint)

Tips to keep your RCAs Confidential • Have an attorney opinion on file advising the facility against submitting SE data to Joint Commission voluntarily • Before triennial survey – go through documents pulled with a fine tooth comb – Remove “executive session” minutes or documents associated with attorney/client or peer review privileges from your binders • Have a good process for staff to report their gripes and complaints internally!

Is the Event Reviewable? Does the event meet the definition of a “reviewable” sentinel event? • A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. (2010 Hospital Accreditation Standards Manual)

Is the Event Reviewable? Criteria for sentinel event – The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition. . . . . Or is it?

Reviewable List All of the following are automatically reviewable – suicide, death of full term infant, patient abduction, discharge of infant to wrong family, rape, hemolytic transfusion reaction, wrong site, side, patient surgery, retained foreign body, severe neonatal hyperbilirubinemia, prolonged fluoroscopy

Root Cause Analysis • Regardless of whether you choose to self report or not – you must complete a thorough and credible RCA within 45 days of knowledge of the event • If you are self reporting – you will submit your RCA and action plan to TJC within 45 days of the event.

Determination Process – If not self reported • The office of quality monitoring will schedule a conference call with the facility representative to determine if the event meets criteria for review • You will need to be prepared for this call with case specific data (times/dates, etc) • If the event is determined to be “reviewable” the facility must select a review option within 5 days

Office of Quality Monitoring • There are 5 nurse reviewers in the OQM • They report to the executive director • They all do on-site and in-facility face to face reviews as well as the submitted reviews • The OQM also handles complaints • ( . . . .they have the “SE” mindset when reviewing complaints . . . )

Your Options • Option 1 – go to TJC with your SE policy, RCA and action plan; return home with your documents • Option 2 – on site visit by JC reviewer of SE policy, RCA and action plan only • Option 3 – on site survey / interviews with staff, document review (no viewing of RCA) • Option 4 – standards based survey

But first things, first . . . A Credible and Thorough Root Cause Analysis and Action Plan

Successful Root Cause Analysis • First and foremost – a good reporting system – you have to know when something happens (45 day time frame) • Second but just as important – safety culture where staff feel free to participate and share information – It takes much longer to the get the root cause when staff are withholding information.

Parts of your Sentinel Event & RCA Process that are Important to TJC

Your Sentinel Event Policy • The reviewer will make sure that the definition in your policy matches the joint commission definition. • They may offer other suggestions to your policy • Make sure you followed your own policy - for example, your policy may require that the RCA will completed within 30 days – Make sure your dates comply

Participants in your Root Cause The reviewer is looking for: • Interdisciplinary representation • Senior Leadership presence • Physician involvement • We were asked to provide our attendance sheets with names backed out – but titles / role included

Your Literature Review • Do a credible literature review • If there is prevailing literature that addresses prevention of the event – they will want to see that you have either implemented it or addressed it in some way (why it “wouldn’t” work in your facility) • We were asked to provide the bibliography of our literature review – They keep the bibliography.

Your Root Cause • Thorough • Use the event as the “key” to access all processes associated in any way • Example if you are analyzing an event in the OR – include the process that occurred before the OR and after the OR – including follow up care • Ask the questions from the tool – even if you think they don’t apply (environment, leadership, etc) – we tend to focus on the process itself

Your Action Plan • This is what the reviewer is MOST interested in • The reviewer uses the “A Framework for Root Cause Analysis and Action Plan in Response to a Sentinel Event” (on TJC’s website)

Required in Action Plan • For each of the findings identified in the analysis as needing an action, indicate the planned action expected, implementation date and associated measure of effectiveness. OR. … • If after consideration of such a finding, a decision is made not to implement an associated risk reduction strategy, indicate the rationale for not taking action at this time

Required in Action Plan • For each item - Risk Reduction Strategies and Measure of Effectiveness should be listed • There should ultimately be action plans in potential areas – not just the area where the event occurred (e.g. OR event but may apply to the Cath Lab also) • Cite any literature that was used in the redesign of the process (credibility)

TJC additions to your action plan • Most likely – the reviewer will suggest / add new action plans • Based on their conversation with you and • Based on their previous experience with subject event • Based on literature • Don’t be afraid to explain why the action plan is not appropriate for your facility (lesson learned)

Forms and tools

Other tools From the Joint Commission Website 1)Joint Commission Framework for Sentinel Event 2) RCA tool guideline – Good questions for facilitators of teams Internal Tools • Root Cause Worksheet (adapted for each type of SE) • Disclaimer / Sign in Sheet • Facilitator Guidelines - include blurb written on white board

Questions? mccammon@kershawhealth.org reddy@kershawhealth.org collier@kershawhealth.org

Taking your Sentinel Events & Concerns to TJC