SDS Accreditation Update

PPR options developed by Joint Commission

Options available when legal issues arise

Even before the new accreditation survey process goes into effect, the Joint Commission on the Accreditation of Health Organizations has created options to the self-assessment component of the survey. The periodic performance review (PPR) is an integral part of the Joint Commission’s new accreditation process that debuts in 2004, but health care attorneys and risk managers have been afraid that information uncovered in this proprietary self-assessment may be discoverable information in some cases in which the organization is facing a lawsuit.

The concern does not apply to all states equally, says Harold Bressler, general counsel for the Joint Commission. In fact, the law is not clear in any state, which means that different attorneys in each state might interpret their risk differently, but there was enough concern that the Joint Commission put together a task force to develop options to the PPR, he adds. The Legal Issue Task Force comprised representatives from the Joint Commission, the Chicago-based American Hospital Association (AHA), and state hospital associations from Alabama, Connecticut, New Jersey, and South Carolina, he says.

"The greatest concern came from hospitals, but the options we developed are applicable to all organizations, including freestanding same-day surgery centers," says Michael Kulczycki, ambulatory accreditation program executive director for the Joint Commission. Although the PPR is not a public document, and, in fact, surveyors don’t have access to the PPR, some organizations were concerned that an opposing attorney in a legal action might be able to obtain the information, he says.

The PPR is designed as a "no-harm" method for same-day surgery programs to conduct a self-assessment as to compliance with accreditation standards and correct any deficiencies prior to their standard survey, Kulczycki notes. "We created these options for the times that an organization may be vulnerable to a legal action," he adds. "We don’t have any sense of how many organizations will choose the options to the PPR, but we anticipate that there will not be many."

The options are:

• Option 1. The first option is designed to address the "waiver of confidentiality" that could be implied if the same-day surgery program or other health care organization shares self-assessment information with the Joint Commission, says Maureen Mudron, Washington counsel for the AHA. Option 1 enables the organization to:

— perform the midcycle self-assessment and develop a plan of action and measure of success for areas in which accreditation standards were not met;

— attest that the foregoing activities have been completed but, for substantive reasons, advice has been given to the organization not to submit its self-assessment or plan of action to the Joint Commission;

— discuss standards-related issues with Joint Commission staff without identifying specific levels of standards compliance;

— provide measures of success to the Joint Commission for assessment at the time of the complete on-site survey.

• Option 2. This option addresses concerns that different states describe protected information specifically enough to make the information included in a self-assessment fall outside the protected classification, Mudron says. Under Option 2, the same-day surgery program can:

— decline to conduct midcycle self-assessment;

— undergo an on-site survey that is about one-third the length of a full survey at the midpoint of the organization’s accreditation cycle;

— develop and submit a plan of action for deficiencies found in the midcycle survey;

— provide measures of success at the time of the complete on-site survey.

"Organizations choosing the second option will have to pay a fee to cover the costs of the survey, but we have not yet decided what those fees will be," Kulczycki says.

If a same-day surgery program chooses one of the two options to the PPR, it is not necessary to give reasons, he says. The choice is made on the self-assessment form that is accessed through the Joint Commission’s secure web site using the organization’s password.

"The chief executive officer of the organization must also attest to the choice of the option rather than the PPR," Kulczycki adds.

These options were developed to address a worst-case scenario for a Joint Commission-accredited organization, he says. "We don’t expect a large number of organizations to choose them, but we want them to be in place so that we don’t jeopardize the PPR process for everyone," Kulczycki explains. "PPR is a convenient and important tool for health care managers to audit their continual compliance with standards."


For more information, contact:

  • Michael Kulczycki, Executive Director of the Ambulatory Accreditation Program, Joint Com-mission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oak-brook Terrace, IL 60181. Phone: (630) 792-5290. E-mail:
  • Harold Bressler, General Counsel, Joint Com-mission on the Accreditation of Healthcare Organizations. Phone: (630) 792-5672. E-mail: