![]() ■ Interview the hospital’s leaders and staff about their expectations and responsibilities for identifying, reporting on, and responding to sentinel events ■ Review the hospital’s process for responding to a sentinel event ![]() The surveyor makes no determination of whether or not the event is a reviewable sentinel event, but rather will hand off further discussion to Accreditation body in the Sentinel Event Unit of the Office of Quality Monitoring.ĭuring the on-site survey, the assessor /surveyor(s) will assess the hospital’s compliance with sentinel event–related standards in the following ways: ■ Inform the CEO the event will be reported to The Accreditation body for further review and follow-up under the provisions of the Sentinel Event Policy. ■ Inform the CEO that the event has been identified If, in the course of conducting the usual survey activities, a sentinel event is (newly) identified, the surveyor will take the following steps: Surveyors may conduct an assessment of a hospital’s performance improvement practices and procedures, such as root cause analyses and proactive risk assessment. Assessors /Surveyors are instructed not to search for sentinel events during a usual survey or to inquire about sentinel events that have been reported to Accreditation body. When conducting an accreditation survey, the Accreditation body seeks to evaluate the hospital’s compliance with the applicable standards, National Patient Safety Goals, and Accreditation Participation Requirements, and to score those requirements based on performance throughout the hospital over time. ![]() The plan should address responsibility for implementation, oversight, pilot testing as appropriate, time lines, and strategies for measuring the effectiveness of the actions. The product of the root cause analysis is an action plan that identifies the strategies that the hospital intends to implement in order to reduce the risk of similar events occurring in the future. The analysis progresses from special causes* in clinical processes to common causes† in organizational processes and systems and identifies potential improvements in these processes or systems that would tend to decrease the likelihood of such events in the future or determines, after analysis, that no such improvement opportunities exist. A root cause analysis focuses primarily on systems and processes, not on individual perform-Īnce. ![]() Root cause analysis is a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.
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