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
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
 Option
But first things, first . . .
A Credible and Thorough Root
Cause Analysis and Action Plan
Successful Root Cause Analysis
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.
 First
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
likely – the reviewer will suggest /
add new action plans
 Most



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
1)Root Cause Worksheet (adapted
for each type of SE)
2)Disclaimer / Sign in Sheet
3)Facilitator Guidelines - include
blurb written on white board
Questions?
mccammon@kershawhealth.org
reddy@kershawhealth.org
collier@kershawhealth.org