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It will be available on-line starting in 2005
When the Joint Commission on Accreditation of Healthcare Organizations introduced its periodic performance review (PPR) tool in November 2003, there was a single important criticism from the organizations that completed it: They wanted the tool to be available to them all the time, not just once every three years.
The PPR originally was designed to be available to organizations via a secure web site for the three months prior to the midpoint of their accreditation cycle.
In response to requests from the field, the Joint Commission will make the PPR available to an organization on its "Jayco" extranet on a continuous basis starting Jan. 1, 2005.
Having the PPR continuously available allows the user to apply it year round and share it with others in the organization, says Michelle Pelling, MBA, RN, president of the Propell Group, a Newberg, OR-based health care consulting organization specializing in JCAHO compliance and performance measurement.
"The tool will become less daunting and more comfortable to use," says Pelling. "Hopefully, organizations will apply it on an ongoing basis and become more astute as to their level of compliance with the different standards."
"I think that this is great news," says Susan Mellott, PhD, RN, CPHQ, FNAHQ, CEO of Houston-based Mellott & Associates. "However, there is a caveat." JCAHO now is going to require organizations to complete or update the PPR on an annual basis, she explains.
"This will make the quality manager or JCAHO coordinator have to shift focus and to begin utilizing this tool as a continuous assessment of the organization’s readiness," Mellott says.
After an organization has completed the PPR once, it can then utilize its action plans to assure that the elements of performance (EPs) that were not in compliance are now in compliance, or are working toward compliance, she explains.
The continuous availability allows you to record your progress on an ongoing basis, such as process changes that were made after the 18-month self-assessment, says Missi Halvorsen, RN, BSN, senior consultant for JCAHO/regulatory accreditation at Baptist Health in Jacksonville, FL.
"I think it’s great to have it available on a continuous basis because it’s a great tool," adds Halvorsen. The organization does its own self-assessments through a systemwide accreditation committee, with leadership assigned to certain chapters.
"Since we continually assess, the 18-month requirement was not a real challenge for us because we had already done the assessment," she explains.
A major stumbling block could be the fact that JCAHO already has changed the PPR once, effective July 2004, and now all the coordinators who previously went through their tools will have to go back and see what has been changed, says Mellott.
This could be cumbersome, since JCAHO has not clarified how the scoring of specific elements of performance have changed, she explains.
"Also, whenever new standards come out, these will have to be added to your current PPR to see if action plans will be required to meet those EPs," Mellott adds.
[For more information on the PPR, contact:
• Susan Mellott, PhD, RN, CPHQ, FNAHQ, CEO, Mellott & Associates, 5322 W. Bellfort, Suite 208, Houston, TX 77035. Phone: (713) 726-9919. Fax: (713) 726-9964. E-mail: firstname.lastname@example.org.
• Michelle H. Pelling, MBA, RN, The ProPell Group, P.O. Box 910, Newberg, OR 97132. Phone: (503) 538-5030. Fax: (503) 538-0115. E-mail: ProPellGr@aol.com.]