Your agency has one year to prepare for JCAHO annual self-assessments

Joint Commission to require annual PPRs beginning in 2006

Many home health managers initially were apprehensive about periodic performance reviews (PPR), the self-evaluation required by the Joint Commission on the Accreditation of Healthcare Organizations at the midpoint of an accreditation cycle. However, the response to the process following the implementation has been so positive that the Joint Commission will make the PPR an annual requirement beginning in 2006.

The Joint Commission’s goal for Shared Visions-New Pathways — the survey process introduced in late 2002 — always has been to promote continual survey readiness with the PPR as an integral part of that readiness, says Darlene Christiansen, RN, LNHA, director of the Joint Commission’s Standards Interpretation Group and Office of Quality Monitoring. "Comments we received in feedback sessions from organizations that had used the PPR tool were very positive," she notes. "The only negative comments were that the tool was not available on an ongoing basis to be used as part of the organization’s performance improvement program."

Beginning Jan. 18, 2005, the on-line PPR tool will be available to all organizations, not just those organizations that are at the midpoint of their accreditation cycles, Christiansen adds. "This will give everyone a full year to complete their initial PPR. Then they will just need to update it on a monthly or quarterly basis, or whatever timeframe they choose to fit their performance improvement program," she explains.

The incorporation of the PPR tool into a home health agency’s regular performance improvement process will present a true picture of how the organization is meeting the Joint Commission standards on a continual basis, rather than the episodic or point-in-time basis that the midpoint evaluation provides, Christiansen notes.

Being able to access the PPR tool on-line at any time will ensure continual readiness, says Linda J. Doyle, RN, MHA, director of Atmore (AL) Community Hospital Home Health. She is familiar with the on-line tool and says the hospital has a Joint Commission team in place. Doyle serves as a team member with representatives from hospital departments. "We will be using the on-line tool as part of our performance improvement throughout the organization. Although I am on the team and will be given responsibility for completion of the home health-related items, I will rely upon my staff members, including my performance improvement coordinator and clinical director, to complete appropriate parts of the assessment," she explains.

Concerns about information shared in a PPR resulted in the development of options to PPRs that organizations could choose, and those options still will be available, Christiansen adds.

"Each organization has 30 days after the submission of their annual PPR to choose an option for the next PPR if necessary. This means a home health agency can submit a PPR this year, but indicate that next year the organization will choose one of the options to a PPR," she continues. "Organizations that choose a PPR option one year can indicate that they will submit a PPR the following year."

Only home health agencies that are submitting their annual PPRs at the midpoint of their accreditation cycles will have their PPRs reviewed by and commented upon by Joint Commission staff in a consulting session, but other organizations can call the standards interpretation group to ask questions once they’ve completed their PPR, Christiansen points out. "If someone wants to know if implementation of a certain policy or program will meet the requirements of a standard, he or she can call."

Process easy to understand

Feedback from organizations that have completed PPRs shows the process is easy to understand and complete, she says. "The biggest challenge may be to organizations that do not have the computer technology that some larger organizations have. These organizations can get help from the Joint Commission’s information technology group by contacting their account representative," Christiansen suggests. "In fact, I recommend that all organizations work with their account representative prior to submitting their PPR to make sure everything goes smoothly," she says.

Christiansen does point out that an organization’s account representative is the proper contact prior to submission of a PPR and her Standards Interpretation Group is the contact following submission. The Joint Commission is making the tool available on-line throughout 2005 for several reasons, she adds. "We want to give organizations a full year to complete their first PPR before the annual requirement is effective." Not only will this full year give organizations a chance to work out the bugs within their own systems, but it will provide Joint Commission staff with the feedback it needs to further improve the tool, Christiansen explains.

"We don’t anticipate any problems with the technological part of the tool or the completion of the tool," Doyle adds. "This is one more way to make sure we are offering good patient care on an ongoing basis."

For more information about the Joint Commission’s PPR, contact:

Darlene Christiansen, RN, LNHA, Director, Standards Interpretation Group, Office of Quality Monitoring, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5273. E-mail: