Start using the tool for ongoing PI
As of Jan. 1, 2006, the Joint Commission on Accreditation of Healthcare Organizations will require your organization to complete or update its periodic performance review (PPR) once a year, as opposed to every three years. Does this sound like an additional burden for your already overworked staff? If so, you may not be using the PPR as you should.
The goal is to encourage organizations to use the PPR on an ongoing basis as a quality improvement tool, says Darlene Christiansen, RN, LNHA, MBA, director of the JCAHO’s standards interpretation group in the office of quality monitoring. "We need to move away from the idea that this is a seen as an episodic evaluation, because that’s what the issue is right now," she says. "The PPR should be used as a continuous management tool in organizations integrating accreditation standards into business operations."
Instead of looking at the PPR as a "once every three years" requirement, the tool should be updated continually to determine which areas are in compliance and which still require improvements, says Christiansen. "If we live and breathe this and use it as a tool embedded in our performance improvement and risk management systems and update it on a regular basis, then the point of submission on an annual basis becomes a nonissue," she says. "It’s just a matter of pushing a button because the tool is already updated."
Organizations are moving rapidly in that direction, Christiansen reports. "It has been difficult for them because the PPR hasn’t been available on a continuous basis," she acknowledges. "They will now be able to update their plans and measures of success, and give other staff access to that tool, too."
Continuous access to the PPR tool becomes available to organizations as of Jan. 1, 2005.
If your organization uses Option 1, in which the organization performs the midcycle self-assessment but does not submit information to JCAHO, you still will have the ability to work on the PPR on an ongoing basis on JCAHO’s extranet site, but nothing from your working tool will be transferred back to JCAHO, Christiansen notes.
"This provides an educational tool to continually assess compliance with the standards and elements of performance [EPs]," she explains. "Through using that tool, it encourages ongoing compliance with the standards, supports continuous operational improvement, and facilitates a continuous accreditation process."
If your organization chooses Option 1, you also can submit hypothetical situations due to concerns about discoverability. "We have built into our system a way to dialogue about what-if situations, to see if your plans would meet the intent of the standards," she says.
However, organizations will receive the full benefit if they choose to submit the full PPR, which is sent back with comment and approvals from the standards interpretation staff on established plans of action and measures of success, Christiansen explains.
"The positive side of choosing to complete a full PPR is that the organization can openly discuss any standards or EPs that are not fully compliant, and then get an approval of their plan of action and measures of success that is actually documented on the tool," she says.
As of Jan. 1, 2006, when you submit the PPR tool, you also will be required to submit a short summary statement listing the top issues you have addressed, if they were corrected, and what other areas you are working on.
Trend toward full PPR
Organizations are going to become more comfortable submitting the entire PPR, predicts Christiansen. As of June 2004, 61% of organizations that accessed the PPR tool chose to submit their findings via the Joint Commission’s on-line tool, while 32% chose Option 1; 6% 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 of the survey is left with the organization.
Christiansen points to JCAHO’s rollout of its Sentinel Event policy several years ago, when organizations were given several options and alternatives for evaluating their root-cause analysis (RCA), including sending a surveyor to the organization or having designated individuals from the organization come to Chicago to review their follow-up. "At that time, we had received a flurry of information that organizations would not feel comfortable because of the concern over discoverability," she says.
The Joint Commission now is seeing a significant increase in the percentage of organizations that are sending in the complete RCA, Christiansen reports.
Organizations have become more comfortable with the sentinel event follow-up process over time, and the same thing is expected with the PPR, she says. On an annual basis, organizations will have the chance to change their selection for the following year, she notes, but you must do so within 30 days of submission of your selection choice for that year.
"So if in January 2006, I select Option 1, but my attorneys have said, After this year, you can go ahead and do the full PPR.’ Within 30 days of that submission, I need to let JCAHO know that in 2007, I’m going to do the full PPR," Christiansen adds.
"What I’ve been encouraging organizations to do, once the tool becomes continuously available to them, is go back in and address the tool in smaller areas, such as provision of care one month and the medical staff chapter the next, until you can build that tool back up again and assess all the standards," she says.
Many organizations already have processes built internally to go back in and complete the updated tool, Christiansen notes.
"When new standards come out, at this point, we are anticipating that it will be an organizational responsibility," she says. "The reason for that is that we don’t want to surprise the organization by adding something to a document they are currently working on."