1. Definition
Sentinel Events are occurrences that, according to the Joint Commission “…signal the need for immediate investigation and response”.
Hillcrest Educational Centers fully accepts the definition of a sentinel event as employed by the Joint Commission:
“An unexpected occurrence 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.” Permanent loss of function refers to the following domains: sensory, motor, physiologic or intellectual impairment, and it refers to loss of function that is not related to “the natural course of the illness or underlying condition.”
Examples of sentinel events that are relevant to Hillcrest students and programs and that require review by the Joint Commission, as cited in various resources, including the BHC standards and other communications, include but are not limited to:
• Permanent loss of limb or major function (e.g., sensory, motor, physiologic or intellectual impairment).
• A suicide while in Hillcrest care.
• Any student death, paralysis, coma, or other major permanent loss of function associated with a medication error.
• Rape (determined, not an alleged; committed by a student or by a staff).
• Any assault, homicide, or other crime resulting in student death or major permanent loss of function.
• A temporally related death (suicide or homicide) or major permanent loss of function that occurs in the course of or during an unauthorized departure (AWOL) from a Hillcrest campus.
• Any student fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall.
Examples of occurrences that do not qualify as sentinel events requiring review by the Joint Commission (but which probably still require investigation):
• Any “near miss”.
• Full return of limb or function to the same level as before the adverse event, or within two weeks of the loss of function.
• Any adverse or sentinel event that has not affected a Hillcrest student.
• Medication errors that do not result in death or permanent loss of function.
• A suicide following an unauthorized departure (AWOL) from a Hillcrest campus.
• Unsuccessful suicide attempts.
• Unintentionally retained foreign body without major permanent loss of function.
• Death or major permanent loss of function following discharge from a Hillcrest program “against medical advice” (AMA).

2. Policy
In the event of a Sentinel Event at HEC, we will follow the guidelines established by the Joint Commission including properly notifying the Joint Commission of the event within the five day window, per the Joint Commission standards, and commencing a thorough root cause analysis as quickly as possible following the Joint Commission guidelines, and consistent with both DEEC and DESE regulations.
Clearly, any adverse event which qualifies as a sentinel event requiring review by the Joint Commission would also be reportable to Massachusetts DEEC, DESE, and possibly, to DCF as well. HEC will also immediately report any sentinel event to any out of state agencies appropriate to the student referring state, including agencies such as the New York State Justice Center for the Protection of People with Special Needs and the commissioner.

3. Identifying a Sentinel Event
The Hillcrest policy on NOTIFICATION TO CENTRAL OFFICE ADMINISTRATION states:
The Executive Director and/or Senior Vice President of Hillcrest Educational Centers must be contacted when any of the following situations occur. In the absence of the Executive Director and/or Senior Vice President, and/or if he/she is on call at the time, the President/CEO of Hillcrest must be contacted.
a. Incidents of child abuse.
b. Missing or runaway student.
c. Student received a chemical restraint.
d. Staff/student death, and/or injury requiring hospitalization.
e. Serious physical plant/vehicle damage.
f. Loss of power/heat for fifteen minutes. (Contact the Director of Maintenance.)
g. Staff disciplinary action resulting in suspension.
h. Inquiries from press or media.
The notification procedure will include the manager making the notification and/or the Executive Director and/or Senior Vice President, or President/CEO together determining whether the event or situation in question constitutes a Sentinel Event.
In order to institutionalize and standardize event notification procedures, each and every notification to Central Office Administration will include such Sentinel Event determination, regardless of the nature of the event being reported.
This determination will not require documentation unless, of course, it is determined that the event does constitute a Sentinel Event.
4. Adverse Event Procedures
a. If the event/situation does not constitute a Sentinel Event:
Documentation, reporting and investigation procedures, as outlined in Hillcrest Policies and Procedures and in state agency regulations, will be followed, including notifications to state oversight agencies, as necessary.
b. If it is not clear whether the event/situation constitutes a Sentinel Event:
The Executive Director and/or Senior Vice President, and/or President/CEO will confer with members of the Management Team and/or Board of Directors as necessary in order to make such determination. If necessary, a designated manager will confer with the Joint Commissions Standards Clarification section or the BHC section.
c. If the event/situation does constitute a Sentinel Event:
The Executive Director and/or Senior Vice President, and/or President/CEO will notify the Board of Directors and the Management Team. She/he will direct a standing Quality Assurance Team to initiate: 1) an investigation consistent with DEEC and DESE regulations and, 2) a Root Cause Analysis and recommendations for an Action Plan. If necessary, he/she will designate an ad hoc Quality Assurance Team to initiate those activities outlined.
The Joint Commission will be notified within 5 days of the event, or of the discovery of the event, in a manner consistent with Joint Commission standards and protocols (i.e., using resources such as the Sentinel Event form and Framework for Conducting a Root Cause Analysis and Action Plan). A through and credible Root Cause Analysis and an Action Plan will be made available to the Joint Commission within 45 calendar days of the event or of the discovery of the event, as appropriate.
All Massachusetts and out of state oversight agencies will be notified, as required.
5. Root Cause Analysis
The Root Cause Analysis is a process for identifying the causes, factors and conditions associated with an adverse or sentinel event.
The RCA will:
a) focus primarily on systems and processes, not on individual performance.
b) progress from special causes in clinical processes to common causes in organizational processes.
c) identify potential improvements in processes or systems that will decrease or minimize the likelihood of such events in the future.
After analysis, however, the RCA may determine that no such improvement opportunities exist.
Hillcrest will conduct Root Cause Analyses in a manner consistent with Joint Commission standards, protocols and guidelines, as well as with those of state oversight agencies for investigations. Additionally, Hillcrest will seek the advice and guidance from the Commission as needed, and will seek the advice and guidance of state oversight agencies and of the Joint Commission if inconsistent or contradictory requirements exist.
6 Action Plan
The Root Cause Analysis will lead to the development of an Action Plan that identifies the strategies that Hillcrest will consider or will implement to reduce the risk of similar events occurring in the future.
The Action Plan will address:
a) responsibility for implementation of the strategies.
b) responsibility for oversight of the implementation.
c) responsibility for pilot testing, as appropriate
d) time lines.
e) strategies for measuring the effectiveness of the actions for improvement.