• E-mail
• Print
• RSS

What you need to know about periodic performance reviews

HIM Connection, March 9, 2004

Want to receive articles like this one in your inbox? Subscribe to HIM Connection!

One of the most exciting aspects of Shared Visions-New Pathways is that under this process organizations will perform periodic performance reviews(PPRs) approximately 18 months prior to the on-site survey rather than "ramping up" at the last minute. This mid-cycle self-evaluation requires organizations to determine compliance with all applicable JCAHO standards.

The self-evaluation occurs over a secure Internet site, and it requires organizations to review compliance with each standard and all elements of performance. If an organization determines that it is not in compliance with a particular element of performance, the JCAHO requires that it develop a "plan of action" to show how it intends to meet expectations. In addition, organizations may have to develop a "measure of success (MOS)," which is a process to confirm that the methods of compliance were effective.

The JCAHO will review the self-evaluation, plans of action, and measures of success to determine whether they are acceptable. Your organization's accreditation status will not change as a result of the self-evaluation, but surveyors will validate the results of the PPR during the on-site visit.

Sample sizes

Certain standards require you to base compliance on the observation of records. During the on-site visit, surveyors will look at a sample size of 10, but your self-evaluation will require a larger sample size based on your organization's patient population. Remember to use random sampling when selecting records (such as the second or third case, or a computer-generated selection of random cases).

-If you have a population of fewer than 30, sample all cases.

-If you have a population size of up to 100, sample 30 cases.

-If you have a population size of up to 101-500, sample 50 cases.

-If you have a population size of more than 500, sample 70 cases.

Although these JCAHO-approved sample sizes relate specifically to the PPR process and to the MOS after an on-site survey, they are good guidelines to use with ongoing records reviews.

Legal concerns

Some organizations have expressed concern that sharing self-evaluation information with the JCAHO may waive protections against discovery in legal proceedings that are guaranteed by some states. Because of this concern, the JCAHO has provided organizations with two options to fulfill the PPR requirements:

Option one: The organization must complete and attest to the completion of the periodic performance review, plans of action, and measures of success. They will not use the password-protected, automated tool to complete the assessment or submit the results to the JCAHO via the Internet. However, the JCAHO may require conference calls to discuss standards-related issues. At the time of the on-site survey, the surveyors will review the measures of success.

Option two: The organization can choose to have an on-site JCAHO survey instead of completing the self-assessment. The JCAHO will charge a fee and, for any area deemed noncompliant within 30 days of the survey, the organization will have to submit plans of action.

Both options require organizations to attest that their legal counsel has advised them not to participate in the full periodic PPR process. Healthcare facilities will have to determine which option is best for them based upon state laws and legal advice.

This week's excerpt is from the newly-updated book, "Information Management: The Compliance Guide to the JCAHO Standards, Fourth Edition." To order or to learn more, click here.

Kate Alvarez

Editorial Assistant

kalvarez@hcpro.com  

Want to receive articles like this one in your inbox? Subscribe to HIM Connection!

• E-mail to a Colleague
• Print
• RSS
• Archive