Legal aspect of health administration

Legal Aspect of Health Administration

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

Assignment expectations:

  • Explain the basics of Sentinel Event Reporting, including Root Cause Analysis, procedures, timelines, etc...;
  • Discuss the legal implications of Sentinel Events;
  • 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.

Limit your responses to a maximum of four pages. Be sure to properly cite all references.

Sentinel events are "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response" (The Joint Commission, 2009). Joint Commission (JC) accredited organizations are to report sentinel events to the JC within specific periods or face the possibility of having their accreditations downgraded or revoked. A review of the reporting process, as well as the necessary steps needed to establish a comprehensive Risk Management program that builds on these sentinel reports is the focus of this paper.

Sentinel Events and Reporting Timelines

As defined above, a sentinel event is an unexpected occurrence or death in, or immediately following, a hospitalization. These events include, but are not limited to:

  1. Wrong site or wrong patient surgeries
  2. An unexpected death or loss of a body function, which is not related to the patient's condition
  3. Abduction of a patient or infant
  4. Sexual assault of a patient by another patient, staff member, or other person
  5. Discharge of an infant to the wrong family
  6. Retention of a foreign object in a patient after surgery

Once a sentinel event has occurred, the organization has five (5) days in which to notify the JC of the event (Waller Lansden Dortch & Davis LLP, 1998). This five-day period is included in a 45 day time span in which the organization has to complete a "Root Cause Analysis" (RCA) of the event and create an Action plan to correct the issue. An acceptable RCA will focus on the systems and processes that failed not individual performance. A thorough RCA will consider the human and operational factors involved. The JC website specifically lists the phrase of "Why did it happen", and then asks, "Why did it happen" again. The goal of the RCA is to dig deep into the event to flush out all possibilities for its occurrence, and, more importantly, the Action plan's goal is to stop it from happening in the future (The Joint Commission, 2009).

Should the organization fail to submit the RCA/Action plan within the specified 45-day period, the JC will question the organization regarding this failure, and expect an answer within fifteen (15) days. Failure to file these documents within 30 days of this request will result in the JC downgrading the institution's accreditation to "Provisional". If the organization then fails to submit the required reports within another 30 days (60 days from its original due date), the accreditation will be downgraded to "Conditional". Finally, if 90 days has elapsed from the original due date, the Accreditation Committee will be presented with a request for "Denial of Accreditation" for the organization (The Joint Commission, 2009). If the organization fails to submit an acceptable RCA/Action plan within 135 days of the initial event, the organization could lose its accreditation. This loss would affect the organization's ability to file claims for payment from federally funded insurance programs such as Medicare and Medicaid. One other point to make here is that each organization has the latitude to add its own interpretation of what additional issues constitute sentinel events. It is the JC's expectation that organizations will conduct RCA/Action plans on all sentinel events as identified by the JC as well as the organization. Organizations are not however required to file RCA/Action plans with the JC on the additional issues identified by the organization. To assist organizations in this endeavor the JC has placed on its website some very helpful sentinel event tools for use by organizations in developing the RCA/Action plan (The Joint Commission, 2009).

Legal Issues with Sentinel Event Reporting

Any adverse event is unfortunate within the healthcare environment. Sentinel events open the organization up to a vast array of legal issues by their very nature. These events should not have occurred in the first place. Hospitals try to refrain from providing information which can be discoverable, and used against them, with outside agencies. Many times hospitals place such items under "attorney/client privilege" or "peer review privilege". By supplying the JC with a RCA/Action plan, the "privileged" status of these documents can be considered waived by the courts. This waiver comes from the fact that the JC is not an entity that is used as legal counsel or in peer review; it is an independent entity that focuses on the quality of care provided by participating organizations. The U.S Supreme court ruled in 1993 that there be "automatic disclosure requirements . . . of all documents, data compilations, and tangible things in the possession, custody, or control of the party that are relevant to disputed facts at lawsuit initiation." By delivering RCA/Action plans to the JC, a healthcare entity can be "compiling . . . very damaging materials that were intended for safety rather than legal use" (Liang, 2000).

Using Sentinel Events and Total Quality Management To Manage Risks

Continuous Quality Improvement (CQI) and Total Quality Management (TQM) "is an integrative management concept of continuously improving the quality of delivered goods and services" (TUI University, 2010). The concepts of CQI/TQM are ideally obtained through a RCA/Action plan as the result of a sentinel event. There are five elements in the CQI/TQM model. Those elements, as reflected in the PDF documents from the TUI University, Module 3 Home Page, are:

  1. Integration - quality is an integrative process and permeates everything the organization does.
  2. Commitment - Everyone is committed to ongoing improvement
  3. Participation - Everyone in the organization plays a part in the delivery of quality
  4. Standards - There is a drive to exceed current standards and processes
  5. Customer Driven - CQI/TQM is directed at both internal and external customers.

(TUI University, 2010)

A RCA will look at the sentinel event to evaluate what went wrong. The goal will be to improve the quality of care that the organization provides to the community. With an eye toward CQI/TQM, an organization will use lessons it learns from its investigation to put processes and policies in place to prevent the sentinel event from reoccurring. The current model used to complete this action plan is the Plan, Do, Check, Act Model (PDCA). A graphic depiction of this model is located in Appendix A. With the PDCA, an action (Plan) in developed; the process is followed both in "dry runs" and over a predetermined length of time (Do); after the time has elapsed the results are reviewed for accuracy and completeness (Check); (Act)ions are taken on the results and the process starts again until the desired results occur.

The PDCA is a valuable tool in the Risk Manager's toolbox to combat repeat sentinel events. It provides for the collection of data, review of health outcomes, can incorporate trainings/education as part of its function, and constantly monitored for its effectiveness. It also meets the requirement of the JC to develop an action plan for sentinel events. So, though the use of CQI/TQM and incorporating the PDCA model, a risk manager can meet the guidelines for sentinel event reporting as directed by the Joint Commission.


Sentinel event reporting can have both positive and negative implications on JC accredited organizations. If an organization voluntarily provides the JC with a RCA/Action plan, that information could be used against it in legal actions if a court holds that by providing that information to the JC the organization has waived it "privileged information rights." Conversely, that same report, when used in the CQI/TQM process, provides information to the JC regarding faulty processes. The JC then posts this information to its website, which can alert other organizations to faulty processes thus increasing the safety of healthcare overall. The decision to provide the JC with RCA/Action plans can be both detrimental and beneficial to any healthcare organization.


Bulsuk, K. G. (2008, November 21). File:PDCA-Two-Cycles.svg. Retrieved May 12, 2010, from Wikipedia:;

Liang, B. A. (2000, September/October). Risks of Reporting Sentinel Events. Retrieved May 10, 2010, from Health Affairs:

The Joint Commission. (2009, April 1). Sentinel Event Policies and Procedures. Retrieved May 8, 2010, from The Joint Commission:

TUI University. (2010). Module 3 Home - Risk Management. Retrieved May 12, 2010, from TUI University Course Delivery System:

Waller Lansden Dortch & Davis LLP. (1998). JCAHO Sentinel Events Policy -- Advantages, Disadvantages of Self Reporting. Retrieved May 8, 2010, from Find Law for Legal Professionals:

Appendix A

Artistic Depiction of the Plan, Do, Check, Act Model as depicted by Karn Bulsuk and displayed on Wikepidia (Bulsuk, 2008)File:PDCA-Two-Cycles.svg

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