Consider the 'full PPR' option to improve quality

Get feedback directly from JCAHO surveyors

When it comes to completing the periodic performance review (PPR), organizations have more options than ever. The newest is the "full PPR option," which is a regular survey fully staffed by certified surveyors.

Organizations can get direct feedback from surveyors about areas in need of improvement in advance of their actual survey, according to Darlene Christiansen, JCAHO's executive director of accreditation services.

There are now four options to submit the PPR tool: Option 1, in which a midcycle self-assessment is performed but information is not submitted to JCAHO; Option 2, in which the organization undergoes a mid-cycle on-site survey; and Option 3, in which the mid-cycle survey is performed but no written documentation of the survey is left with the organization. For 2006, there is a fourth option — to have a "full PPR" survey, either announced or unannounced.

The cost of doing the full PPR is the same as the cost of doing a full accreditation survey, which is organization-specific, and is dependent on the length of the survey and the number of surveyor days.

The first pilot of the PPR full option was conducted in December 2005 at Alaska Regional Hospital in Anchorage, and only two additional PPR full option surveys have been conducted to date. However, that number is expected to increase, as organizations gain a better understanding of the PPR's purpose, says Christiansen.

"When used effectively, the PPR process will assist organizations in embedding the standards and elements of performance into their daily operations," says Christiansen. "The PPR process is a performance improvement and risk management process. Organizations are just beginning to understand its importance."

The full PPR process is done in a "risk-free environment" and has no direct impact on the organization's accreditation decision, she adds. "The accreditation survey team does not have access to the results of the full PPR survey," says Christiansen.

If an immediate threat that would be considered to impact the safety of patients is discovered during a PPR full survey, the issue would be addressed in a different track through a separate special survey. This would allow the organization to respond appropriately to the identified issues, Christiansen explains.

"At our organization we have always done very well on Joint Commission surveys. But in a nutshell, it has been like preparing for a test — a one-time event every three years, which only expressed your readiness for a test," says Ed Lamb, president/CEO of Alaska Regional. "We felt that we wanted to have the culture established that we were always ready."

Continuous preparedness

Changes were made to ensure continuous preparedness as opposed to a one-year ramp-up, and the decision was made to no longer hire a consultant. After the organization's 2005 survey, they were contacted by the JCAHO to review the experience and invited to pilot the new survey process. "We had an opportunity to work collaboratively with the JCAHO, and as part of that, we agreed to do the full PPR," says Jo Burt, chief clinical officer.

The organization was the first to undergo the full PPR, and staff took a "no holding back" approach with surveyors. "One of the keys to our success was that we told the surveyors to tell us every single thing they found that was not in complete compliance," says Burt. "Our goal was to use it as a tool to become a better organization. With the old survey modality, we were just waiting to hear what it was they had found, instead of asking them to look for any problems."

In general, staff are being more open with JCAHO surveyors due to the culture change of continuous readiness, and with the full PPR process, they welcome the chance to collaborate with the surveyors, says Christiansen.

The JCAHO gave Alaska Regional a three-month window when the unannounced full PPR survey would occur, and surveyors came the very next week, in December 2005. "They caught us totally by surprise," says Norman J. Wilder, MD, MBA, MACP, chief medical officer. "So it was particularly good for us, because they caught us with no chance to try to spiff anything up."

The attitude of the staff toward JCAHO surveys has changed dramatically as a result of the experience with the full PPR, says Wilder. "Previously, people were shaking in their boots. It was a horrible experience, and as soon as it was over it was a sigh of relief, like having bad houseguests," he says. "We're at the point where staff have no fear of JCAHO. They have seen the collaborativeness and realize that they can disagree and discuss with them."

Staff did not even know that it was not a "real" JCAHO survey, says Wilder. "We had been working with our staff all along in letting them know that we would be surveyed under the new system and that we did not know when it would occur," he says. "We treated the survey the same as we would any other."

Responding to surveyors

Several times during the three-day survey, surveyors were challenged by nursing staff who asked them to explain their recommendations. "Staff would say, 'Why is your way better than the way we are doing it?'" says Wilder. "They were taken aback a time or two, to be talked back to. But they realized that our culture had the patient as the focus, and the questions were based on what was best for the patient."

In some cases surveyors even backed down from their criticism of certain processes, adds Wilder.

"A nurse stood by a pain assessment protocol that a lot of personnel had sweated over to develop. The nurse verbalized the reasoning that had gone into the protocol and how it actually did meet the standards even though it was different than other protocols," he says. "They had seen it done differently in other hospitals but admitted our process was also valid so they couldn't fault it. So there is learning going on in both directions."

Surveyors commented on the willingness of the staff to disagree and to engage the surveyors in dialogue. "They were impressed that this would happen because usually the staff is prepared to not raise any questions or discuss items for fear of raising "red flags" or leading the surveyors to problems," says Wilder.

A physician who had written an "unapproved abbreviation" was called over and immediately noted his error, made the appropriate correction, and verbalized the process.

"The surveyor could easily tell that the physician had received all the training, but had just made a mistake," says Wilder. "The saying 'It's hard to teach old dogs new tricks' pretty well summarized the problem, which will be resolved by 'practice makes perfect.'"

Direct feedback

At the end of the full PPR, the organization was given the option of counting the full PPR as their actual survey and will be doing the Level 2 PPR option in December 2006.

"In the unannounced environment, the option of having a full PPR unannounced survey count as the organization's full survey is still under management discussion," says Christiansen. "As we continue to do full PPR surveys, we will ask for feedback from organizations."

The organization was able to get direct feedback from JCAHO to determine if standards actually were being met. "We were able to send policies and procedures directly to them and get validation that this indeed meets the standards," says Burt.

With any PPR option, an organization can take advantage of this by asking for a follow-up conference call with JCAHO's standards interpretation staff, says Christiansen. Official approval or official validation can be given only when the organization opts to have a conference call with standards interpretation to discuss the outcome of its PPR process, she explains.

"I would highly recommend the full PPR process," says Wilder. "The new process allowed our staff a comfort level in asking questions of the surveyors regarding observations they have seen that could help us to improve our systems and processes. It also gave our staff a level of confidence to challenge judgments of our processes and systems."

[For more information, contact:

Jo Burt, Chief Clinical Officer, Alaska Regional Hospital, 2801 DeBarr Road, Anchorage, AK 99508. E-mail:

Norman J. Wilder, MD, MBA, MACP, Chief Medical Officer, Alaska Regional Hospital, 2801 DeBarr Road, Anchorage, AK 99508. Telephone: (907) 264-1166. Fax: (907) 264-1143. E-mail:

Ed Lamb, President/CEO, Alaska Regional Hospital, 2801 DeBarr Road, Anchorage, AK 99508. Telephone: (907) 264-1754. E-mail:]