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The Joint Commission on Accreditation of Health Care Organizations (JCAHO) requires reporting of what are called sentinel events. After thorough research please respond to the following questions:

Explain the basics of Sentinel Event Reporting, including Root Cause Analysis, procedures, timelines, etc...;

Explain the relation between Sentinel Events, Root Cause Analysis and TQM/CQI;

Discuss how healthcare administrators can combine the principles of TQM/CQI with Sentinel Event Reporting and Root Cause Analysis in developing an effective risk management program.

3 to 4 pages of information please.

Solution Preview

Hi,

Interesting topic! One approach to help you with an assignment like this one is to address each quesiton from various research sources, which you can then draw on for your final copy. This is the approach that this response takes. I also attached one supporting resource, some of which this response is drawn.

RESPONSE:

QUESTION: The Joint Commission on Accreditation of Health Care Organizations (JCAHO) requires reporting of what are called sentinel events. After thorough research please respond to the following question.

Although the above statement suggests otherwise, one source says that JCAHO does NOT require reporting of sentinel events, and in fact, estimate that only 1% to 2% that occur in US hospitals actually ever get reported perhaps due to fear of legal actions. Rather, JCAHO reports that it is better that the hospital learns form the data collected through the Root Cause Analysis and associated plan of action. In other words, reporting is optional, but the organization still needs to engage in the process. http://books.google.com/books?id=dNxG_vIIbugC&pg=PA46&lpg=PA46&dq=jcaho+requires+reporting+of+what+are+called+sentinel+events&source=web&ots=qGpWZG5onp&sig=2CbL1QsRbafRJJI-B2MGd4qMLqY

Instead, the JCAHO policy is aimed at:

(1) Improving care
(2) Focusing attention of underlying cause and risk reduction
(3) Increasing knowledge about sentinel events, their causes and ways to prevent them
(4) Maintaining public confidence in the accreditation process http://books.google.com/books?id=dNxG_vIIbugC&pg=PA46&lpg=PA46&dq=jcaho+requires+reporting+of+what+are+called+sentinel+events&source=web&ots=qGpWZG5onp&sig=2CbL1QsRbafRJJI-B2MGd4qMLqY

So, JCAHO sets standards to follow in handling Sentinel Events, which the healthcare organization needs to comply to, but reporting is optional. However, healthcare organizations often (if not always) require that all sentinel events to be reported to the HRM department, which is understandable.

Now, let's look closer at the following questions:

1. Explain the basics of Sentinel Event Reporting, including Root Cause Analysis, procedures, timelines, etc.

Sentinel Events are relatively infrequent, clear-cut events that occur independently of a patient's condition commonly reflect hospital system and process deficiencies; and result in unnecessary outcomes for patients. It is believed that through investigating the frequency of Sentinel Events, it is likely to be reduced by examining the settings in which they occur, and identifying system changes required, which may reduce the likelihood of similar occurrences in the future. http://www.health.vic.gov.au/clinrisk/sentinel/ser.htm

For example, a Sentinel Event is any ...

Solution Summary

In relation to the Joint Commission on Accreditation of Health Care Organizations (JCAHO), who requires reporting of what are called sentinel events, this solution explains several concepts and/or relationships between concepts e.g. basics of Sentinel Event Reporting, including Root Cause Analysis, procedures, time lines, etc... and the relation between Sentinel Events, Root Cause Analysis and TQM/CQI. It also explains how healthcare administrators can combine the principles of TQM/CQI with Sentinel Event Reporting and Root Cause Analysis in developing an effective risk management program. Supplemented with an article on Root Cause Analysis and Risk Reduction Action Plan.

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