Alternative 4 may have reduced reporting risk
Alternative 4 may have reduced reporting risk
Question: When the Joint Commission on Accreditation of Healthcare Organizations first introduced its sentinel event policy, risk managers expressed a great deal of concern that the reporting requirements could force providers to make damaging information available to plaintiffs’ attorneys. Now that some time has passed, have those fears been borne out?
Answer: It appears that changes in the Joint Commission’s reporting requirements may have reduced that risk substantially, but there are plenty of similar risks on the horizon, says Fay Rozovsky, JD, MPH, DFASHRM, a risk management consultant in Richmond, VA. Rozovsky is president of the American Society for Healthcare Risk Management (ASHRM) in Chicago, and she has served as chairwoman of ASHRM’s sentinel event task force and as the ASHRM representative on the Joint Commission-American Hospital Association national legal task force, which has been addressing risk managers’ concerns about the sentinel event policy.
In 1998, ASHRM convinced the Joint Commission to make changes in the already controversial sentinel event policy to make it less of a lawsuit kit for plaintiffs’ attorneys, as some risk managers described it. Risk managers feared that the policy essentially forced the health care provider to gather all the data on a potentially litigious event, describe in great detail how the provider was at fault in allowing the adverse event to take place, and then make all that information legally accessible to plaintiffs’ attorneys. All a plaintiff’s attorney would have to do is obtain the sentinel event reports and then show a jury that the hospital admitted fault. As the sentinel event policy was written, the hospital practically has no choice but to admit fault in some way.
The sentinel event policy enables the Joint Commission to require a report on a particularly egregious error that suggests there may be a systemic problem threatening the health and safety of patients. The facility must present a report on the error, why it happened, and how the systemic error will be corrected. In some cases, the Joint Commission will put the organization on accreditation watch, meaning the organization’s accreditation is threatened until the matter is resolved.
In response to concerns from ASHRM and other groups, the Joint Commission made these changes:
- Self-reported sentinel events need not contain patient or caregiver identifier information.
- Health organizations will submit two separate reports to the Joint Commission — the root-cause analysis and the risk reduction plan. Previously, that information was required to be provided in one report. This change was made to facilitate rapid return of the root-cause analysis to the health care organization, which is crucial because that analysis can be the most damaging information in a lawsuit.
Once data are abstracted for entry into the sentinel event database, the Joint Commission returns root-cause analysis to the provider. In situations in which the analysis must be considered by the Joint Commission’s accreditation committee, all copies of it are destroyed once the committee has completed its review.
In addition, the Joint Commission provided a reporting option known as Alternative 4 for organizations that have experienced sentinel events but have significant legal concerns about sharing sentinel event information. Under Alternative 4, an organization may opt to have a specially trained surveyor conduct an on-site review of the organization’s response to a sentinel event rather than provide the root-cause analysis of the sentinel event to the Joint Commission. That review process includes interviews with organization staff and analysis of relevant documents to obtain information on how the organization approaches the evaluation of a sentinel event.
In addition, the chief executive officer of the organization is required to affirm in writing that use of any other alternative for review under the sentinel event policy would increase the risk of waiving existing confidentiality protections for the information.
The Joint Commission originally introduced Alternative 4 as only a pilot project but recently made it a permanent part of the sentinel event system. That’s an indication the Joint Commission has found the option workable, Rozovsky says.
Even if the sentinel event policy does not pose the same risk it once did, Rozovsky says, risk managers still have plenty of reason to worry about damaging information getting into the wrong hands. The recent concern about medical errors has prompted a number of initiatives, both federal and state, that threaten to divulge information now kept private, she says.
"It’s all the more important now that we start thinking about how we deal with the evidentiality issues of sentinel event reporting and other kinds of reporting that may come out of some of these initiatives for addressing medical errors," she explains. "The issue of evidentiality is not dead at all. In fact, it’s been crystallized by the Institute of Medicine Report and the Quality Interagency Coordination [QuIC] task force report."
QuIC endorses mandatory reporting
The QuIC report endorses most of the IOM recommendations, including the call for mandatory reporting of medical errors and the formation of a new agency to oversee the reduction of medical errors. In addition, the federal Health Insurance Portability and Accountability Act (HIPAA) regulations go into effect over the next few years, requiring all sectors of the medical community to have a technology system in place to protect the confidentiality of medical information. As HIPAA takes effect and other initiatives are enacted, Rozovsky says, there may be many problems from the overlap of reporting systems, plus the conflict between state and federal laws.
For instance, HIPAA will allow state laws to take precedence if they are stricter than the federal law for protecting patient confidentiality. But Rozovksy questions how that will apply to organizations working in various states, as well as how to define some of the terms in HIPAA.
"Who is my business partner? Would the Joint Commission be considered my business partner because of the way we work with them?" she asks. "If so, what can I transfer to the Joint Commission without patient consent? The issue just keeps spouting up like a geyser, over here and over there."
The bottom line, Rozovsky says, is that there is no cohesive national policy on protecting health care information. The problem is bigger than what risk managers first recognized with the sentinel event policy, she says.
"I still fear that what we were afraid of in the sentinel event policy will come back and bite us, all more so after the IOM and QuIC reports," she says. "I’m afraid it’s going to get more complex before it gets better."
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