Will new survey process threaten confidentiality?

In addition to preparing staff for unannounced surveys and ensuring continuous preparedness, you also may have looming concerns about legal disclosure related to the Joint Commission on Accreditation of Healthcare Organizations’ new accreditation process.

Concerns involve the periodic performance review (PPR), an integral component of the new survey process that requires you to conduct a midcycle self-assessment, develop a plan of action to address identified areas of noncompliance, and identify measures of success to demonstrate that problem areas have been resolved.

What has hospital risk managers worried is the possibility that PPR information is potentially discoverable. The likelihood of an organization’s PPR becoming publicly available is minimal, according to Patrice L. Spath, BA, RHIT, a health care quality specialist with Brown-Spath & Associates in Forest Grove, OR. "However, some hospital attorneys have expressed concerns about loss of confidentiality protections once the information is transmitted to the Joint Commission."

Although most organizations are expected to use the standard PPR process, the Joint Commis-sion has approved two other options in order to mitigate concerns.

Option 1. The organization performs the midcycle self-assessment, develops the plan of action and measures of success, and 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. The measures of success are provided for assessment during the complete on-site survey.

Option 2. The organization need not conduct a midcycle self-assessment and develop a plan of action. Instead, an on-site survey will occur at the midpoint of the organization’s accreditation cycle, which will be approximately one-third the length of a typical full on-site survey. The organization will be charged a fee to cover the costs of the survey, and will develop and submit a plan of action to address any areas of noncompliance found during the on-site survey, and provide measures of success for assessment at the time of the complete on-site survey.