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    17 Sentinel Event Policy

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    المعتزبالله جاب الله
    The Joint Commission International Sentinel Event Policy outlines procedures for responding to sentinel events reported by organizations undergoing accreditation or certification. Key aspects of the policy include: 1) Organizations must conduct a timely root cause analysis and develop an action plan to reduce risks when a sentinel event occurs. 2) Root cause analyses will be considered acceptable if they focus on systems and processes, identify specific clinical and organizational causes, and recommend changes to reduce future risks. 3) Organizations must submit their root cause analysis and action plan to JCI for review within 45 days of an event. JCI will then assign a follow-up activity, typically a Strategic Improvement Plan.

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    17 Sentinel Event Policy

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    المعتزبالله جاب الله
    135 views2 pages
    The Joint Commission International Sentinel Event Policy outlines procedures for responding to sentinel events reported by organizations undergoing accreditation or certification. Key aspects of the policy include: 1) Organizations must conduct a timely root cause analysis and develop an action plan to reduce risks when a sentinel event occurs. 2) Root cause analyses will be considered acceptable if they focus on systems and processes, identify specific clinical and organizational causes, and recommend changes to reduce future risks. 3) Organizations must submit their root cause analysis and action plan to JCI for review within 45 days of an event. JCI will then assign a follow-up activity, typically a Strategic Improvement Plan.

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    The Joint Commission International Sentinel Event Policy outlines procedures for responding to sentinel events reported by organizations undergoing accreditation or certification. Key aspects of the policy include: 1) Organizations must conduct a timely root cause analysis and develop an action plan to reduce risks when a sentinel event occurs. 2) Root cause analyses will be considered acceptable if they focus on systems and processes, identify specific clinical and organizational causes, and recommend changes to reduce future risks. 3) Organizations must submit their root cause analysis and action plan to JCI for review within 45 days of an event. JCI will then assign a follow-up activity, typically a Strategic Improvement Plan.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    135 views2 pages

    17 Sentinel Event Policy

    Uploaded by

    المعتزبالله جاب الله
    The Joint Commission International Sentinel Event Policy outlines procedures for responding to sentinel events reported by organizations undergoing accreditation or certification. Key aspects of the policy include: 1) Organizations must conduct a timely root cause analysis and develop an action plan to reduce risks when a sentinel event occurs. 2) Root cause analyses will be considered acceptable if they focus on systems and processes, identify specific clinical and organizational causes, and recommend changes to reduce future risks. 3) Organizations must submit their root cause analysis and action plan to JCI for review within 45 days of an event. JCI will then assign a follow-up activity, typically a Strategic Improvement Plan.

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    © All Rights Reserved
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    Joint Commission International Accreditation and Certification Policies

    2015 Joint Commission International


    Sentinel Event Policy

    Sentinel Event Policy


    Purpose. To identify the procedure for responding to sentinel events reported in an organization actively

    involved in Joint Commission Internationals (JCI) accreditation or certification process.


    Policy

    1) JCI Accreditation reviews organizational activities in response to sentinel events in its accreditation or
    certification process, including full accreditation or certification surveys (initial and triennial) and, as
    appropriate, focused surveys.
    2) At a minimum, an organization must include those events in its sentinel event policy that are subject
    to review described under the standard that addresses sentinel events from the accreditation program
    for which they are applying and the JCI Sentinel Event Policy.
    3) Accredited organizations and certified programs are expected to identify and respond appropriately to
    all sentinel events occurring in the organization or associated with services that the organization
    provides, or provides for. Appropriate response includes conducting a timely, thorough, and credible
    root cause analysis; developing an action plan designed to implement improvements to reduce risk;
    implementing the improvements; and monitoring the effectiveness of those improvements.
    4) A root cause analysis will be considered acceptable if it has the following characteristics:
    The analysis focuses primarily on systems and processes, not individual performance.
    The analysis focuses on specific causes in the clinical care process as well as common causes in the
    organizational process.
    The analysis repeatedly digs deeper.
    The analysis identifies changes that could be made in systems and processes (either through
    redesign or development of new systems or processes) that would reduce the risk of such events
    occurring in the future.
    5) A reviewable sentinel event is subject to review by JCI Accreditation and includes any occurrence that
    meets defined criteria (see point 2 above).
    6) If an organization wishes to report an occurrence that is subject to review by JCI Accreditation, the
    organization can submit the report to JCI Accreditation.
    7) If JCI Accreditation becomes aware (either through voluntary self-reporting or otherwise) of a sentinel
    event that meets the above criteria and the event has occurred in an accredited organization or certified
    program, the organization is expected to do the following:
    Prepare a thorough and credible action plan within 45 calendar days of the event or of becoming
    aware of the event.
    Submit to JCI Accreditation its root cause analysis and action plan, or otherwise provide for JCI
    Accreditation evaluation of its response to the sentinel event.
    After JCI Accreditation determines that an organization has conducted an acceptable root cause
    analysis and developed an acceptable action plan, JCI Accreditation notifies the organization that
    the root cause analysis and action plan are acceptable and assigns an appropriate follow-up
    activity, typically a Strategic Improvement Plan (SIP) due in four months.
    8) An event that occurred more than one year before the date JCI Accreditation became aware of the
    event may not, in most cases, be reviewed under the Sentinel Event Policy. In such a case a written
    response will be requested from the organization, including a summary of the processes in place to
    prevent similar occurrences.
    9) All root cause analyses and action plans will be considered and treated as confidential by JCI
    Accreditation.

    Joint Commission International Accreditation and Certification Policies


    2015 Joint Commission International
    Sentinel Event Policy
    10) An on-site review of a sentinel event will usually not be conducted unless it is determined that there is
    a potential ongoing immediate threat to patient health and safety. All are immediately referred to JCI
    Accreditation for authorization to conduct a focused survey. If a focused survey is conducted as a
    result of a threat to health and safety, the organization will be billed an appropriate amount based on
    the established fee schedule to cover the cost of conducting such a survey.
    11) If in the course of conducting the usual survey activities a sentinel event is identified, the surveyor
    will take the following steps:
    Inform the organizations CEO that the event has been identified.
    Inform the CEO that the event will be reported to JCI Accreditation for further review and followup under the provisions of the Sentinel Event Policy.
    12) During the on-site survey, the surveyor(s) will assess the organizations compliance with sentinel
    eventrelated standards in the following ways:
    Review the organizations process for responding to a sentinel event.
    Interview the organizations leaders and staff about their expectations and responsibilities for
    identifying, reporting, and responding to sentinel events.
    Ask for an example of a root cause analysis that has been conducted in the past year to assess the
    adequacy of the organizations process for responding to a sentinel event. Additional examples
    may be reviewed if needed to more fully assess the organizations understanding of and ability to
    conduct root cause analyses. In selecting an example, the organization may choose a closed
    case to demonstrate its process for responding to a sentinel event.
    13) If JCI Accreditation receives an inquiry about the accreditation or certification decision of an
    organization that has experienced a reviewable sentinel event, the organizations accreditation or
    certification decision will be reported in the usual manner without making reference to the sentinel
    event. If the inquirer specifically references the specific sentinel event, JCI Accreditation will
    acknowledge that it is aware of the event and currently working or has worked with the organization
    through the sentinel event.

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