Quality managers: Periodic performance review can be a powerful quality tool

Don’t hesitate to put your processes under the microscope

Do you shudder to think of the workload involved in completing the periodic performance review (PPR) now required by the Joint Commission on Accreditation of Healthcare Organizations? Are you finding yourself solely responsible for all the data collection this entails? Is your goal to do the minimum required to pass muster with surveyors?

If so, you might want to rethink your approach. "The PPR is a very, very useful tool for the organization," emphasizes Susan Mellott, PhD, RN, CPHQ, FNAHQ, CEO of Mellott & Associates, a Houston-based consulting firm specializing in health care performance improvement. "But if you want to get the full benefits out of it, then you need to do it correctly and not rush through it."

There’s no way around it: Completing the PPR is extremely time-consuming, acknowledges Michelle Pelling, MBA, RN, president of the ProPell Group, a Newberg, OR-based health care consulting organization specializing in JCAHO compliance and performance measurement.

"However, our position is that the organization should be assessing its compliance with standards anyway. So why not use the tool that the surveyors will use?" she asks.

The goal of doing the PPR should be to assess the level of quality of care in your organization, not merely to prepare for a survey, Mellott adds. "I suggest doing it every 18 months. That’s a lot of work, but that is your continuous quality improvement," she says.

By completing the PPR, you will be able to demonstrate progress made in areas that require improvement, not only to Joint Commission surveyors, but also the Centers for Medicare & Medicaid Services or internal regulatory compliance, Mellott notes. "They all have slightly different requirements, but now you have evidence that you have either fixed any problems or that you are in the process of doing so," she says.

Remember, there is a rationale behind every standard, and these constitute a minimal level of compliance and certainly not best practice, says Mellott. "To pass JCAHO just says you have met minimum standards, but could you do better? Absolutely," she adds. "The more in-depth you go with the PPR, the higher level of service you will provide. So even if the surveyors go easy on you, you will be making yourself better."

At Round Rock (TX) Medical Center, team leaders were charged with assessing each process, scoring with samples, and proving compliance. "Just because we had a policy didn’t mean we were doing the process well," says Pamela R. Voss, FACHE, FASHRM, the organization’s director of risk management.

"In other words, the proof had to be in the pudding with demonstrated results and outcomes. Many processes were streamlined or improved with the assessment."

To use the PPR as an effective performance improvement tool, do the following:

• Use a team approach.

Many organizations are having difficulty finding qualified individuals in-house who have both the time and ability to perform the in-depth assessment required by the PPR, Pelling acknowledges.

As a result, there may be a tendency to put the entire burden of completing the PPR squarely on the quality manager’s shoulders, but this is a mistake, Mellott says.

"I do not think there is any way, even in a small hospital, that a quality manager can do all the data collection," she notes, adding that there are more than 100 elements of performance (EPs) for restraint alone. "No one person can be responsible for collecting all that data. Coordinating it, yes, but not doing the whole thing."

If a single individual were to complete the PPR, he or she would be forced to do a cursory overview and only wind up wasting resources, Mellott notes.

Here are some recommendations:

— Form teams, each responsible for collecting data for EPs in a given function area.

At Round Rock Medical Center, director-level team leaders were designated for each of the respective JCAHO chapters, with additional team members as needed depending on the chapter scope.

"Each team leader was responsible for assessment, scoring, and reporting of findings for their chapter, and could ask assistance from whatever department or person who could provide needed information," Voss says.

Assign a lead person to oversee the completion of the PPR, supported by a small group of trained individuals who will assess each area and gather the necessary data.

It’s not a good idea to assign each department director to take a piece of the PPR, since these individuals often have different skills and abilities than are needed to assess and measure appropriately, Pelling cautions.

"There are also a number of standards that cannot be categorized by department and need to be assessed by individuals who understand the cross-functional nature of the various processes," she says.

Have a designated person do all the required data entry for data control and data quality issues.

This should be someone who is a data-entry expert," says Pelling, who adds that this individual would not be expected to interpret the data, which already should be done by the small group assembled to complete the PPR.

• Involve staff in the data collection process.

The expectation that unit staff have a thorough understanding of the standards and how they apply to clinical practice is an integral part of the new survey process, Mellott notes. By reviewing charting done in their own units, staff will have a greater understanding of what documentation is required and why, and in the process, will be a big help in completing the data requirements for the PPR.

Mellott gives the example of data collection to measure compliance with documentation of assessment, reassessment, plan of care, discharge planning, and modification of the plan of care.

She suggests having each staff member take a closed patient record to check whether the required documentation is there and discussing how to apply standards to documentation at staff meetings.

"That way, you have your sample for your score, and staff are learning at the same time," explains Mellott. "If you have five nursing units and 10 nurses from each unit each take a record, you can add all those scores together and that becomes your data to show whether you are in compliance. At the same time, it also serves as your medical review record requirement."

Education was a key component of the PPR process at Round Rock Medical Center. "We made significant strides with knowledge base of requirements among the team leaders, members, and staff," Voss says.

"It was like the lights went on in several staff members’ minds that they were grasping the intent, requirements, and understanding why some processes are important," she adds.

With this approach, the PPR becomes much more than simply assessing compliance with accreditation requirements, and serves as a confidence-booster and educational tool for staff, Voss explains.

• Do an in-depth assessment several months before starting the PPR.

The idea is to correct any deficiencies or compliance issues so that your organization can minimize the number of areas that will require complete action plans, Pelling explains.

• Determine compliance with every EP.

Don’t shirk from asking tough questions when looking for evidence of compliance, Mellott advises. "If you don’t look at every single EP, the PPR is not as effective or useful," she emphasizes. "If the EP is asking whether you have a policy, don’t stop there. Dig a little deeper. You need to address every one of the bullets in that EP."

If you do a cursory PPR without assessing every EP individually, you’ll wind up getting a general picture as opposed to ensuring that every single requirement is met, and that is selling your organization short, Mellott argues.

"It depends on what your intention is," she says. "If your intention is only to pass JCAHO, then maybe you’ll be OK. But if your intention is to improve your way of doing everything, then doing the entire PPR is a better way of doing that."

• Understand PPR terms.

Here are definitions for some of the terms used for the PPR:

1. Measures of success.

A measure of success is numerical or quantitative and reflects whether an action was successful or sustained, Pelling says.

Standards with an "M" noted only need to be measured if you are not in compliance, Mellott explains. In other words, if a standard has six EPs and you are not in compliance with two of these, you would only need a measure for the two standards you are not in compliance with.

"You don’t have to collect data just to answer those. There is a lot of misconception out there about this," she adds.

For example, the EP may ask if you have a policy with certain items, and if so, has it been implemented, and is the policy being followed consistently. You may have the policy, but if it is not being used consistently, you would have to create a measure to demonstrate that.

This is different from the "C" standards, which require at least 10 samples of data to show your results, Mellott says. "For a C standard, you might look at 10 different patients to see how you rate yourself. But any of the A, B, and C standards may also have the M’ there," she explains.

2. Corrective action plan.

A corrective action plan should reflect the deficiency identified, how the organization plans to correct it, a time frame, responsible individuals, and how they will measure their results to know whether the actions they took improved compliance, Pelling says.

"Developing measures/indicators to assure that there are ways to determine success or failure prior to the on-site survey is critical," she says. "The organization should use the JCAHO-recommended sample sizes."

3. Partial compliance.

This indicates that the organization is not fully compliant with all of the principles that comprise an element of performance, or that all of the principles have been met, but not for 12 months, says Pelling.

In many cases, you may be compliant with some, but not all, of the EPs for a given standard, Mellott warns. "You really need to look at what the EPs are asking," she says. "The tendency is to say Well, we’ve got a policy on that, so we’re all right,’ without really looking at the policy and making sure it covers what it needs to."

Some organizations are skipping over the timeframe requirements, but you are not in compliance unless these are met, Mellott advises. "You can have the best policy in the world, but if it’s only been in place for six months, you will still get a zero," she says. "In that case, you don’t need a measure; you just need to keep doing it. So your measure would be, Are we still doing what we should be doing?’"  

[For information on completing 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: mellottandassoc@att.net.

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.

Pamela R. Voss, FACHE, FASHRM, Director, Risk Management, Round Rock Medical Center, 2400 Round Rock Ave., Round Rock, TX 78681. Phone: (512) 341-5286. Fax: (512) 341-5364. E-mail: pamela.voss@stdavids.com.]