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Question: We recently had a sentinel event at our facility and responded appropriately with a report to the Joint Commission on Accreditation of Healthcare Organizations and a root-cause analysis. Now, a managed care organization (MCO) is asking for the same information and claiming that we are required to turn it over. Is that right?
Answer: Sort of. This may come as a surprise to many quality and peer review professionals, but you should report a sentinel event to MCOs. You don’t have to, but the Joint Commission would be happier if you did.
You should be careful not to disclose too much information, but the MCO is entirely within its rights to ask for some explanation of the event.
The new JCAHO 2001-2002 Comprehensive Accreditation Manual for Health Care Networks has an added section on sentinel events that says, "Accredited networks are expected to identify and respond to all sentinel events occurring in the network or associated with services that the network provides, or provides for." That means that any MCO accredited by the Joint Commission is required to gather information on sentinel events in which its members are involved.
But because there are serious concerns about peer review privilege and confidentiality, the Joint Commission does not actually require providers to give that information to the MCOs, says Lynne Bergero, MHSA, associate project director in the division of research at the Joint Commission. In fact, the Joint Commission is planning to issue a clarification in the next month or so to emphasize that there is no such requirement.
"This question has come up a lot, so we thought a clarification was necessary, even though we’re not changing the standard itself," she says. "Some providers thought they were supposed to give their root-cause analysis, and that’s not what we intended. We would like to see them cooperate with the networks to promote better patient safety, but we’re not saying you have to turn over a lot of sensitive information."
Many hospital peer review professionals don’t know about this expectation, says Sherry Dunn, LMSW, ACSW, CCM, clinical quality improvement specialist with Corphealth in Fort Worth, TX, an MCO specializing in behavioral health care. Dunn says she has encountered resistance from some providers who don’t understand why she is asking for information about the sentinel event. "Some wonder why we need to know and just say it’s none of our business. They say they can’t show us the medical records because they’re confidential when they’ve actually been handing over other medical records all along. There’s just a lack of knowledge about the requirements here."
Reporting to an MCO is a separate track from reporting the sentinel event to the Joint Commission, she explains. No one expects you to send the same information to both. And in fact, you shouldn’t. Dunn has seen some providers send their entire root-cause analysis to the MCO. As someone who previously worked in quality management for a hospital, she knows that is a big mistake.
"I never would have sent that kind of information to the managed care group because then it becomes public information and you lose all your peer review privilege," Dunn says. "You expose yourself to tremendous lawsuits, and it’s not even necessary. That’s not the information we expect from providers."
So what does the MCO want to see? Most MCOs will be satisfied with a much simpler explanation of the sentinel event and the provider’s response, she says. The provider should explain what happened and show that the event was treated seriously, and there was a meaningful response by the organization.
"Usually, as long as they are looking at the quality issue and can show us they are taking corrective steps, that’s enough," Dunn says. "We want to see that they considered it in terms of quality improvement, that it’s been through a quality committee, and they didn’t dismiss it as just an isolated incident. We’ll usually get a summary of the corrective action, not the specifics. They’ll say that they educated the staff, changed policies, and disciplined some people, without explaining all the specifics."
According to Bergero, that sort of report would please the Joint Commission. She emphasizes that though the Joint Commission does not require providers to give sentinel event information to the MCO, it wants the two parties to share information within the constraints of peer review and privacy issues.
In some cases in which Corphealth says patient safety is an issue, it may send Dunn or other representatives for a site visit. Remember that only the MCO whose patient was involved in the sentinel event can demand such information. Other MCOs may ask about a sentinel event in the course of accrediting your organization, but you are not obligated to provide the same information to them.
The exact mechanism for how you report the sentinel event may differ from one MCO to another. Some MCOs have a clause in their contracts that obligate the provider to volunteer the information within a reasonable time, but others like Corphealth wait until they find evidence of the sentinel event themselves. Corphealth is pleased if a provider comes forward with the information on its own, but the MCO doesn’t mind if it finds out itself. In most cases, sentinel events are spotted by the MCO’s utilization review staff.
Corphealth is accredited by the National Committee for Quality Assurance (NCQA), not the Joint Commission, so it reports the sentinel event information to the NCQA. Other MCOs accredited by the Joint Commission will pass on the information to that group.
Also, keep in mind that the report to the MCO serves an important purpose. The MCO will use the information to assess the quality of your organization and whether you should be accredited to treat their customers. At Corphealth, such reports are sent to the chief medical officer and the risk management committee for review. If they are not satisfied with the report, Corphealth may ask for more information.
"Ultimately, if we’re not satisfied with what we’re given and the provider resists giving us more information, it could threaten their accreditation with Corphealth," she says. "We would have to forward it to our credentialing committee with a recommendation for decredentialing, or at least flag it as a something to consider the next time they come up for credentialing."
Dunn saw just such a case in the past few months. A Corphealth customer committed suicide while under treatment, which constitutes a sentinel event, and then the provider would not submit adequate information. That provider already had a history of questionable care and insufficient quality improvement, so the refusal to provide adequate data about the sentinel event was the final straw. Corphealth decided not to renew the provider’s accreditation.