Accreditation

Tracers, PPR approach give one hospital perfect JCAHO survey

Briefings on Accreditation and Quality, September 1, 2005

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Learning objective: After reading this article, you will be able to

1. explain how to use tracers to conduct your period performance review (PPR)

2. identify how to focus your PPR efforts on critical areas

3. describe how to involve staff in the PPR process

Intensive mock tracers and a focused PPR helped one New Jersey hospital come away from its July survey with no requirements for improvement.

Meadowlands Hospital Medical Center in Secaucus, NJ, credits the PPR and clearly defining data for its measures of success for acing its survey, says Wren Lester, the hospital's corporate director of performance improvement (PI).

"We were very prudent in defining very clear numerators v. denominators [for the measures of success], Lester says. "Some facilities have a vague measure."

Chart your success

The hospital selected PPR option 1-in which the organization uses the JCAHO's printed PPR tool and discusses standards-related issues with the commission without giving any specifics-and set up "chapter" teams of leaders and department heads to do a full analysis of the Comprehensive Accreditation Manual for Hospitals ( CAMH ), Lester says.

The hospital's JCAHO surveyors suggested that teams could also be organized around the priority focus areas, Lester says.

When the chapter teams gave an element of performance a score of 1-partial compliance-or 0-noncompliant-they developed a measure of success. The hospital measured all indicators for 12 months, broke the data down by month, and posted each measure on a graph to identify problems and improvements, Lester says.

The graphs even went up on the walls in each unit so staff could track progress, Lester says.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

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