SDS Accreditation Update

One year to prepare for annual self-assessments

JCAHO to require PPRs each year starting 2006

Same-day surgery managers were apprehensive about periodic performance reviews (PPRs) by the Joint Commission. However, the response has been so positive to the self-evaluation required at the midpoint of an accreditation cycle that the Joint Commission will make the PPR an annual requirement beginning in 2006.

The Joint Commission’s goal for "Shared Visions-New Pathways," the survey process introduced in late 2002, always has been to promote continual survey readiness, with the PPR being an integral part of that readiness, says Darlene Christiansen, RN, LNHA, director of Joint Commission’s Standards Interpretation Group and Office of Quality Monitoring.

"Comments we received in feedback sessions from organizations that had used the PPR tool were very positive," she says.

"The only negative comments were that the tool was not available on an ongoing basis to be used as part of the organization’s performance improvement program," Christiansen adds.

Beginning Jan. 18, 2005, the on-line PPR tool will be available to all organizations, not just those organizations that are at the midpoint of their accreditation cycles, she says. "This will give everyone a full year to complete their initial PPR, then they will just need to update it on a monthly or quarterly basis, or whatever timeframe they choose to fit their performance improvement program," Christiansen explains.

The incorporation of the PPR tool into a same-day surgery program’s regular performance improvement process will present a true picture of how the organization is meeting Joint Commission standards on a continual basis rather than the episodic or point-in-time basis that the midpoint evaluation provides, she notes.

Margaret G. Acker, RN, MSN, chief executive officer of Blake Woods Medical Park Surgery Center in Jackson, MI, found the PPR to be very helpful. "The on-line tool makes it easy to assign different parts to different staff members so that it is easier to complete," she says. "I will use the PPR on an ongoing basis because it does help you focus upon the things you should be doing."

Because Acker’s same-day surgery program chose to have an unannounced survey, she points out that having completed the PPR prior to the surveyors’ arrival meant she and her staff were well-prepared for the survey even without knowing when it would occur. Because all organizations will undergo unannounced surveys beginning in 2005, the PPR is a good way to prepare, Acker adds.

Concerns about information shared in a PPR resulted in the development of options to PPRs that organizations could choose, and those options still will be available, Christiansen says.

Each organization has 30 days after the submission of the annual PPR to choose an option for its next PPR if necessary, she explains. "This means that a same-day surgery program can submit a PPR this year but indicate that next year the organization will choose one of the options to a PPR," Christiansen says. "Organizations that choose a PPR option one year can indicate that they will submit a PPR the following year."

Only same-day surgery programs that are submitting their annual PPRs at the mid-point of their accreditation cycle will have their PPRs reviewed and commented upon by Joint Commission staff in a consulting session, but other organizations working on their PPRs at other times in their accreditation cycle can call the standards interpretation group to ask questions, Christiansen notes. (See resources, below.)

"If someone wants to know if implementation of a certain policy or program will meet the requirements of a standard, he or she can call," she explains.

Feedback from organizations that have completed PPRs shows that the process is easy to understand and to complete, Christiansen notes.

The biggest challenge may be to organizations that don’t have the computer technology and support that some larger organizations have, she warns. These organizations can obtain help from Joint Commission’s information technology group by contacting their account representative, Christiansen suggests.

"In fact, I recommend that all organizations work with their account representative prior to submitting their PPR to make sure everything goes smoothly," she says.

Christiansen points out that an organization’s account representative is the proper contact prior to submission of a PPR to handle questions about the process, and her Standards Interpretation Group is the contact following submission to handle questions related to standards.

The Joint Commission is making the tool available on-line throughout 2005 for several reasons, she notes. "We want to give organizations a full year to complete their first PPR before the annual requirement is effective," Christiansen says.

Not only will this full year give organizations a chance to work out the bugs within their own systems, but it also will provide Joint Commission staff with the feedback it needs to further improve the tool, she adds.

"Everything included in the Joint Commission standards and the PPR is something we should be doing anyway," Acker says. "Having the tool available all of the time will be an important management tool for our performance improvement program."


For more information, contact:

  • Margaret G. Acker, RN, MSN, Chief Executive Officer, Blake Woods Medical Park Surgical Center, 2775 Blake Road, Jackson, MI 49201. Phone: (517) 787-2906.
  • Darlene Christiansen, RN, LNHA, Director, Standards Interpretation Group and Office of Quality Monitoring, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5273. E-mail:

For Joint Commission standards-related questions, call the standards interpretation group at (630) 792-5900. To submit your question by e-mail, go to, choose "contact us" at bottom of home page, then scroll down to "standards questions." Click on the link to the on-line question form, and submit that after you’ve completed it.