Take the opportunity to obtain valuable feedback
To share or not to share? That’s the question for many organizations currently in the thick of the decision-making process for whether to send in the results of their periodic performance review (PPR) to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Some organizations are choosing not to share their PPR results with JCAHO because they fear that the information may become discoverable and be used against them in a medical liability or malpractice case, explains Michelle Pelling, MBA, RN, president of the ProPell Group, a Newberg, OR-based health care consulting organization specializing in JCAHO compliance and performance measurement.
"Each organization should seek counsel from its hospital attorney and decide whether it feels comfortable taking the risk," she says.
To address this concern, JCAHO gave several options for organizations to choose from. "There are several ways you can tell us you are completing the self-assessment," says Darlene Christiansen, RN, LNHA, MBA, director of the Joint Commis-sion’s standards interpretation group and office of quality monitoring.
As of mid-April 2004, 57% of the 1,981 organizations that accessed the PPR opted to submit their findings via the JCAHO’s on-line tool.
Of the organizations that selected a PPR option, 33% selected Option 1, in which the organization performs the midcycle self-assessment but does not submit information to JCAHO; 9% selected Option 2, in which the organization undergoes a midcycle on-site survey; and less than 1% selected Option 3, in which the midcycle survey is performed, but no written documentation or report of the survey is left with the organization.
Here are items to consider for each option:
• If you send in your results via the Joint Commission’s on-line tool.
"We call that the full PPR process,’" says Christiansen. The organization evaluates itself against all standards and elements of performance, and for noncompliant areas, develops a plan of action and measure of success, which it submits to JCAHO.
Standards interpretation staff review the content and schedule a telephone conference with the organization, which is required if noncompliant areas are identified.
The purpose of that call is solely to support the organization in its performance improvement activities, Christiansen stresses. "The PPR has absolutely no impact on the accreditation decision," she notes.
"There is no integration of the PPR tool to any data related to the future performance of the organization, as long as the organization follows through with the process," she says.
At that time, JCAHO will discuss your plans of action and measures of success and either will approve them or suggest a way to modify your approach. "We document that, and the plan is approved," Christiansen says.
"The dialogue is not disciplinary — it is our way of working with the organization to ensure that we understand that is the path it is headed down and we all agree," she explains.
If there are any questions, they are resolved at the time of the discussion, she adds.
When your survey does occur, the surveyor cannot question what standards interpretation already has been approved during the telephone dialogue, notes Christiansen.
"The surveyor will only ask for any measures of success the organization has been working on, to be sure they are staying on track with what they said they were going to do," she says. "They don’t go back and review the entire tool. They don’t have access to that."
• If you choose Options 1, 2, or 3.
If advised by legal counsel that there are concerns about discoverability of information in the PPR, the organization may choose from three additional options.
However, it’s important to note that by not submitting your PPR to JCAHO, you are giving up the opportunity for counseling and correction by a surveyor, which could modify your action plans, Pelling says.
"One benefit of turning in the PPR is if JCAHO approves the action plans submitted, another surveyor cannot disagree with the action plan when conducting the triennial on-site survey," she adds.
For Option 1, the organization attests to the fact that it has done a full assessment and has been advised by legal counsel that it should choose this option. Although the organization is not required to submit anything, a phone call to discuss the self-assessment still can be requested.
"We encourage them to do this, so that they can discuss standards-related issues if they wish," Christiansen says.
During that discussion, if the organization doesn’t want to disclose actual situations, it can still talk about theoretical ones to obtain feedback from JCAHO, Christiansen points out.
"For instance, if an organization is changing its ED to a trauma center in the next budget year, it can discuss systems and processes, and document that we have discussed those situations," she says.
"This process can provide guidance, although it is not as supportive as the full PPR or Option 2," Christiansen explains.
For Options 2 and 3, the organization still is accountable for doing a full self-assessment, and a surveyor is assigned to come on-site to review priority areas at the midpoint of the accreditation cycle. This timing allows for the organization to implement plans of action to achieve a 12-month track record.
"The surveyor is generally out there for about one-third the time of the triennial survey, so if you are having a nine-day survey, we would send one surveyor out for three days for a very focused review," Christiansen says. "Again, even though it occurs during a survey, this is part of the PPR review process and thus has no impact on the accreditation decision."
In Option 2, however, the organization is required to develop a plan of action and measures of success for any noncompliant standards, submit these to JCAHO, and then follow the same course as the full PPR process, with a dialogue required if noncompliant standards are identified, resulting in an approved plan of action and measures of success.
For Option 3, the surveyor leaves no report on-site after the survey, but does give the organization a verbal update and finding report.
"Nothing is ever sent to the organization, and the organization does not have to send us the completed plan of action," Christiansen notes.
Future of the PPR
When surveys become unannounced sometime after January 2006, an annual update will be required for the PPR, but only for those areas identified as needing improvement. "It will not be burdensome to the organization. The requirement shouldn’t scare organizations, because it will only assist them," she explains.
"It will simply be a matter of continually updating it through your PI processes, she adds. It might be only a half-dozen areas a year — you might be addressing leadership one month and patient care processes another month."
Quality managers have reported that the PPR process has helped them to fully understand the meaning of the standards and how they should be interpreted, according to Christiansen.
"Now all the EPs are available to them and are no longer hidden, as they were prior to 2004, when all the measurable characteristics were in the surveyor’s laptop. Now, you are working with the same information that the surveyors do," she says.
When the PPR tool was rolled out by the Joint Commission in November 2003, an important criticism was voiced by many of the organizations that completed it.
"They said it was a very beneficial tool, but really wanted it to be available all the time. If the PPR is really part of their PI process, they need to address issues as they occur, not just once every three years," Christiansen points out.
The Joint Commission currently is working on filling this need, to make the PPR tool continually available.
"It was an important lesson for us, that if indeed they were to use this as a performance improvement process, they would need to be able to continually go into that and allow their staff access to it as well," she adds.