JCAHO Update for Infection Control

JCAHO addresses PPR liability concerns

Lawyers, risk managers cite disclosure dangers

The Joint Commission has created two options designed to address legal disclosure concerns related to its Periodic Performance Review (PPR). The PPR is an integral component of the Joint Commission’s new accreditation process that debuts in 2004.

The PPR process requires each accredited organization to conduct a midcycle self-assessment against applicable Joint Commission standards; develop a plan of action to address identified areas of noncompliance; and identify measures of success for validating resolution of the identified problem areas when the organization undergoes its complete on-site survey 18 months later.

Under the usual PPR process, organizations will be expected to share all of this information with the Joint Commission at the midcycle point. Joint Commission staff will work with the organization to refine its plan of action to assure that its corrective efforts are on target.

Legal implications

However, health care lawyers and risk managers recently have expressed concerns about the potential discoverability of PPR information, particularly where it is shared with the Joint Commission.

To address these concerns, the Joint Commission has been working with health care legal experts to explore potential options for mitigating these concerns while maintaining the integrity of the PPR process. The two options developed and approved thus far are as follows:

Option 1

This approach has been designed to address "waiver of confidentiality" concerns that could arise if the organization shares sensitive performance information with the Joint Commission.

Under Option 1, the organization does the following:

  • Performs the midcycle self-assessment, and develops the plan of action and measures of success.
  • Attests that it has completed the foregoing activities but has, for substantive reasons, been advised not to submit its self-assessment or plan of action to the Joint Commission.
  • May discuss standards-related issues with Joint Commission staff without identifying its specific levels of standards compliance.
  • Provides its measures of success to the Joint Commission for assessment at the time of the complete on-site survey.

Option 2

This option has been designed to address concerns that the very requirement for a self-assessment at a specified point in time may create a vulnerability to discovery of the self-assessment findings and any related plan of action.

Under Option 2, the organization does the following:

  • Need not conduct a midcycle self-assessment and develop a plan of action.
  • Will undergo an on-site survey at the mid-point of the organization’s accreditation cycle.
  • The survey will be approximately one-third the length of a typical full on-site survey.
  • The organizations will be charged a fee to cover the costs of the survey.
  • Develops and submits to the Joint Commission a plan of action to address any areas of noncompliance found during the on-site survey. The Joint Commission will work with the organization to refine its plan of action.
  • Provides its measures of success to the Joint Commission for assessment at the time of the complete on-site survey.