Contingency Business Risk Planning Sentinel Events

EHNAC Background

The Electronic Healthcare Network Accreditation Commission (EHNAC) is a federally-recognized, standards development organization and tax-exempt, 501(c)(6) non-profit accrediting body designed to improve transactional quality, operational efficiency and data security in healthcare. EHNAC represents a diverse cross-section of healthcare stakeholders. Electronic health networks, payers, hospitals, physicians, consumer groups, financial services firms, security organizations and vendors are all working together to establish sound accreditation criteria for self-regulation (“Accreditation Criteria”).  Accreditation promotes standards, administrative simplification and open competition in the marketplace. Each organization that meets the Accreditation Criteria, i.e., an EHNAC accredited organization, improves business processes, encourages innovation, improves quality of service, ensures HIPAA compliance, and expands market opportunities.

EHNAC Mission Statement

To promote standards-based accreditation within the healthcare data exchange industry.

EHNAC Objectives

EHNAC recognizes that its accredited entities (“Accredited Entities”) and accreditation candidates (“Accreditation Candidates”) operate in a dynamic business environment that includes many business and legal variables ancillary to the fundamental scope of EHNAC’s accreditation process.  However, because that environment involves  business and legal risks that may impact (1) EHNAC accrediting operations; and (2) accreditation eligibility, EHNAC has developed a collaborative  process to (A) enable Accredited Entities and Accreditation Candidates to identify significant business, financial, operational and legal developments that have the potential to compromise or undermine their  ability to meet the EHNAC Accreditation Criteria (“Sentinel Events”) and (B) provide EHNAC with written notification of such Sentinel Events.

Business risk evaluation is necessary for EHNAC to accomplish the following objectives in a timely manner:

• Acquire timely knowledge of Sentinel Events (described in Exhibit A) that may affect the accreditation status of an Accredited Entity or Accreditation Candidate.
• Maintain credibility of EHNAC as a nationally recognized accreditation body.

1. What is a Sentinel Event?

A Sentinel Event is any significant  development, action or change in the business, financial, operational or legal status of an entity, which occurs, (1) with respect to an Accredited Entity, after accreditation, or, (2) with respect to an Accreditation Candidate, after the application has been submitted to EHNAC.  The change in status may be based on any one or more of the Sentinel Events indicated below or described in the Sentinel Events Exhibit A.

2. Notificaton Process: When should EHNAC be notified?

The Executive Director of EHNAC must be notified in writing of the occurrence of any Sentinel Event (described in Exhibit A) that could adversely impact the ability of an Accredited Entity or Accreditation Candidate to fulfill obligations relating to the EHNAC Accreditation Criteria.  Written notification in the manner described in Section 3 below must be received by EHNAC no later than three (3) business days from when the Sentinel Event occurs.  Failure to provide such notification could result in loss of Accreditation, loss of Candidacy status or such other action as EHNAC may determine to be appropriate.

3. How Should EHNAC be Notified?

As part of the notification process, the Accredited Entity or Accreditation Candidate shall provide the Executive Director of EHNAC with the “known facts,” attached to the written notification, and shall continue to provide EHNAC written notice of additional relevant information as such information becomes “known facts.”  The written notice shall be delivered to EHNAC by email sent to This e-mail address is being protected from spambots. You need JavaScript enabled to view it or by a fax sent to (860) 760-6630.

“Known facts” shall include, but not be limited to, (A) any relevant data, information or circumstances regarding a Sentinel Event  which an Accredited Entity or  Accreditation  Candidate (i) is required by law, by a contract to which it is a party, or by any other legal obligation to report or disclose to a third party, or (ii) has disclosed in a public statement or in any non-confidential manner; (B) reports or information that must be reported to a government agency and (C) all findings of fact in the form of an  agency action by a duly authorized regulatory agency or in a judgment by a court of original jurisdiction, notwithstanding any subsequent appeals.

The written notification should include the following information:

   A.  Name of the individual reporting the Sentinel Event (company name, individual name, title, address, phone number, and email address.

   B.   Description of the Sentinel Event

   C.   Date the Sentinel Event occurred.

   D.  EHNAC Accreditation impact(s) or considerations that could materially and adversely affect the company’s compliance with the Accreditation Criteria; e.g., changes in key executive management in a small company or release of a press announcement in a public company.

  E.   Other factual information EHNAC should consider.

   F.   If the Sentinel Event has resulted in non-conformity with the Accreditation Criteria, a proposed plan to restore conformity, i.e., an explanation  in reasonable detail of how the company will promptly reestablish conformity with all applicable EHNAC Accreditation Criteria..

   G.  Appropriate documentation should be submitted along with the disclosures, e.g., press releases, etc.

4. What Constitutes a Sentinel Event?

The following is an illustrative but not exhaustive topical list of Sentinel Events. Refer to the attached Sentinel Event Exhibit “A” for detailed explanations.

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• Entering into an agreement of sale to sell or otherwise directly or indirectly divest an Accredited Entity or an Accreditation Candidate.
• Entering into an agreement to purchase or otherwise directly or indirectly acquire an Accredited Entity or Accreditation Candidate.
• Entering into a new agreement to outsource an Essential Function.[1]
• Financial impairment of an Accredited Entity or Accreditation Candidate.
• Insolvency/bankruptcy filing.
• Change in ownership or control> 25%.
• Disruption of service to customers > 8 hours for telecom, or security violation
• A security breach that is reportable as a matter of state or federal law.
• Workforce reduction by > 15%.
• Key management changes.
• Company fine(s) of > $100K for regulatory violations, marketing or advertising practices, antitrust violations, or tax disputes.
• Adding or significantly modifying a physical location in which an Essential Function is provided
• Significant events associated with Essential Functions that are outsourced to third parties including but not limited to their addition or significant modification of physical locations.

Downloadable Documents

Sentinel Event