In response to concerns of health care attorneys and risk managers that information contained in a health care organization’s periodic performance review (PPR) may be discoverable in a legal action, the Joint Commission on Accreditation of Healthcare Organizations developed these options to the PPR:
• Option 1 addresses the waiver of confidentiality that can be implied if the home health agency shares the self-assessment information with the Joint Commission. When an organization chooses Option 1, it may:
— Perform the PPR and develop a plan of action and measure of success for areas in which accreditation standards were not met.
— Attest that the foregoing activities have been completed, but for substantive reasons, advice has been given to the organization not to submit its self-assessment or plan of action to the Joint Commission.
— Discuss standards-related issues with Joint Commission staff without identifying specific levels of standards compliance.
—Provide measures of success to the Joint Commission for assessment at the time of the complete on-site survey.
• Option 2 addresses concerns that different states describe protected information specifically enough to make the information included in a PPR fall outside the protected classification. Under this option, an organization can:
— Decline to conduct a PPR.
— Undergo an on-site survey approximately one-third the length of a full survey at the point at which a PPR is required.
— Develop and submit a plan of action for deficiencies found in the survey.
— Provide measures of success at the time of the complete on-site survey.
• Option 3 allows a midcycle on-site survey to be conducted by surveyors rather than by the organization itself. Under this option:
— No written documentation or report of the survey is left with the organization.
— Findings are conveyed orally to management.
— At the subsequent full survey, surveyors will be aware of the findings of the midcycle survey but will not discuss them with the organization unless asked to do so, regardless of whether any particular standard had been found out of compliance. Instead, surveyors will focus on compliance with those standards at the time of the full survey.