Accreditation

Surveyor guidance clarifies PPR findings and track record

Briefings on The Joint Commission, September 1, 2006

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

After reading this article, you will be able to

1. -describe how surveyors assess track records for plans of action during surveys

2. list five steps to build a plan of action

In July, the JCAHO provided surveyors with guidance about how to handle findings that organizations already identified in the periodic performance review (PPR), gave them clearance on checking plan of action (POA) due dates, and developed instructions on how to survey using track record from POA dates.

PPR findings

In performing the PPR, the organization identifies standards/elements of performance (EP) that are noncompliant. The organization develops and submits the PPR to the JCAHO with POAs (and measures of success [MOS], if required by an EP) for how it will get each of the noncompliant standards/EPs into compliance.

At the time of the organization's call with the standards interpretation group (SIG), POAs and their implementation due dates are approved.

There have been questions about what steps surveyors should take if a noncompliance finding that they make matches a finding in the organization's PPR. Surveyors don't have access to an organization's PPR data, so, technically, they wouldn't know about the organization's finding, call with the SIG, or approved POAs. Surveyors can ask for MOS data only.

New information

These questions are answered in the July issue of a newsletter that the JCAHO distributes to surveyors, which was obtained by Briefings on JCAHO.

"The surveyor should assess track record with reference to the approved POA implementation deadline," the newsletter reads.

The inclusion of track recordis important new information, according to Kurt Patton, MS, RPh, former JCAHO executive director of accreditation services and principal of Patton Healthcare Consulting, LLC, in Glendale, AZ, who was shown a copy of the newsletter.

"This is the first time the JCAHO has put this in print," Patton says. He adds that the concept was discussed during the launch of the new survey process, but it has never been added to the Comprehensive Accreditation Manual for Hospitals.

The newsletter goes on to give an example, paraphrased in the following bullets:

  • An organization is out of compliance with MM.2.20
  • The organization has its PPR conference call with the SIG on March 15 and its approved POA for MM.2.20 has an implementation date of May 1
  • An unannounced survey occurs on May 22
  • Surveyors should expect to see compliance with MM.2.20 since May 1

    "Specifically, if the surveyor identifies a compliance problem with the same issue as identified by the organization, and the organization states that [it has] a plan approved by SIG with an implementation date of May 1 the surveyor should ask the organization to see the approved POA and date," the newsletter continues.

    If a surveyor can verify that the implementation date has not yet passed, a finding will not be documented, according to the newsletter.

    But if an organization does not want to show a surveyor the information, surveyors are instructed in the newsletter to document the finding and flag it with a note, indicating that the organization has an approved POA and implementation date from the SIG. When the survey report gets to JCAHO's Central Office, staff will pull the organization's PPR and verify whether it is the same issue and, if necessary, change the score based on track record.

    • This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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