Accreditation

Greeley Reflections

Accreditation Connection, March 8, 2010

Issues surrounding the PPR

Part 1 of 3

The Periodic Performance Review (PPR) is an annual self-assessment process aimed at supporting continuous accreditation readiness and performance improvement activities required by The Joint Commission.

There are traps that many organizations can fall into when scoring the electronic assessment. One pitfall is to score too harshly and end up with a large number of non-compliant standards that must then have Measures of Success (MOS) demonstrated to show compliance. There have been organizations that have scored 30 to 40 standards noncompliant, which resulted in an extremely complex and difficult action plan in which to comply. This dilutes the performance improvement efforts and can lead to only partial compliance when completed. It can become an annual exercise in futility since success is hard to obtain.

It is not necessary for an organization to go through the entire electronic PPR standard-by-standard each year. Use of the previous year’s PPR can act as a baseline and allow for review of compliance with new or changed standards. Focus efforts on the priority standards for compliance and MOS activities. You should narrow the focus for compliance to standards that put your organization at the highest risk.

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