Accreditation

Periodic Performance Review

Accreditation Monthly, February 6, 2004

Dear Colleague,

This month, I would like to discuss the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) newest option to fulfill the periodic performance review (PPR) accreditation participation requirement. Effective January 1, 2004, all accredited organizations will be expected either to conduct a mid-cycle self assessment of all applicable standards, or select an approved alternative to the full periodic performance review.

As you are aware, the JCAHO adopted two PPR options in late 2003 in response to legal concerns regarding the potential discoverability of PPR information shared with JCAHO.

In Option 1, the organization performs the mid-cycle self-assessment but does not submit the information to JCAHO.

In Option 2, the organization undergoes a mid-cycle, on-site survey.

In the newest option (3), an on-site survey would be conducted, similar to option 2. However, no written report of findings would be left on-site. They would be discussed orally and at the time of your next triennial survey. Surveyors would be knowledgeable of your mid-cycle findings, but would not discuss them unless requested by the hospital. Surveyors will, however, focus on compliance with those recommendations during your full survey.

The following grid details the components of each PPR option:

Components of Each PPR Option
Full PPR PPR Option 1 PPR Option 2 PPR Option 3

Submit data on customized PPR tool online.

Use printed PPR tool, retain results on-site.

On-site surveyor at 18 month point, written report.

On-site surveyor at 18 month point, verbal report.

Equivalent to scoring tool on surveyor laptop.

Must affirm honest self-assessment.

One person for a third of normal time using tracer method.

One person for a third of normal time using tracer method.

Plans of action, MOS submitted online.

Plans of action, MOS stay on site.

Plans of action, MOS submitted 30 days post survey.

No plan of action or MOS are required.

Reference tools, education available.

Affirm that legal counsel required this option.

Affirm that legal counsel required this option.

Affirm that legal counsel required this option.

Formal telephone review session.

Telephone review session is optional.

Limited in scope by PFP. Fee required.

Limited in scope by PFP. Fee required.

Official plan of action approval; at next full survey surveyors will not question design, only MOS implementation.

May submit phone or written questions and gain official plan approval; at next full survey surveyors will not question design, only MOS implementation.

A 45-day post survey phone call to approve or amend plans and MOS; at next full survey surveyors will not question plan design, only MOS implementation.

At next full survey, surveyors will have results of the mid-cycle review, although not limit their review to only these issues.

I hope you continue to find this information of value in your ongoing preparation efforts. If The Greeley Company can be of any further assistance, please do not hesitate to give us a call at 888/749-3054.

Sincerely,
Steven Bryant
Practice Director
Accreditation and Regulatory Compliance

For more information on our accreditation and regulatory compliance consulting services, click here or contact Denise Paquette, Practice Manager, at dpaquette@hcpro.com or call 888/749-3054, ext. 3436.

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