Safety

Complete your PPR requirement by staying on track

Ambulatory Safety Monitor, May 12, 2005

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Effective in 2006, JCAHO accredited organizations must annually complete a periodic performance review (PPR). Although the requirements remain the same for ambulatory facilities as hospitals, the challenges may differ.

With fewer staff to take on the workload in an ambulatory center, the process may seem overwhelming. Don't be daunted by the volume of work in the beginning, however-get focused and involve as many staff as you can, says Gina Dolsen, RN, BSN, MA, consultant at Health Inventures in West Chester, OH.

Organizations can access the PPR self-assessment tool through Jayco, the JCAHO's extranet. You must report your PPR results to the JCAHO triennially in 2005 and annually beginning in 2006.

The PPR serves as a type of internal survey. You may choose from four options to complete it: the full PPR, option 1, option 2, or option 3. The differences lie in the level of involvement the JCAHO takes in the process.

Dolsen worked on the pilot study of the PPR in the summer of 2003. With 25 years in the ambulatory field, she now has four PPRs under her belt. In her experience, Dolsen says most ambulatory organizations choose the full-disclosure PPR option.

"The facilities I've worked in feel the full PPR is consistent with their organizational goals," she says. "However, the JCAHO provides for a variety of organizational needs through various option programs."

Make the right choice for your facility

Before you can begin all of the paperwork involved in the PPR, determine which option serves your needs best.

Dolsen offers these tips for all ambulatory organizations to get started:

  • Clearly understand your options before choosing one-every organization is different. Discuss issues specific to your facility with a JCAHO account representative.

  • Ask your governing board and legal counsel which option they would prefer.

  • Evaluate whether your organization contains the expertise to complete the option of choice. If not, research and hire an outside consultant to assist you.

Keep the process on schedule

Without the proper focus, the PPR can intimidate your staff. Set a deadline for yourself and break down the big due date into smaller deadlines. For example, Dolsen completed each of the PPRs she worked on in three months. Within those three months, she organized three meetings with set goals for each target date.

Dolsen recommends the following process:

  • Premeeting: Pick a point person who will act as the coordinator of the project. For example, the leader could be the director of nursing or an administrator.The point person then chooses the PPR team. Typically a coordinator selects these people based on their daily duties. For example, the infection control (IC) nurse may take on the IC component.

  • First meeting: Meet with your new team, consultant, JCAHO representative, or any people involved in the process. In this overview meeting, the coordinator will explain the nuts and bolts of the PPR-from why it's important to how to complete it. Assign chapters to the corresponding staff and give them a target date for review.

  • Second meeting: Bring the paper notes back to the group. Try to identify
      - where you are in compliance
      - what is noncompliant or what is unclear
      - suggestions on how to reach compliance

    At this point you can begin inputting information into the JCAHO tool.

  • Third meeting: Focus on your noncompliant areas and prioritize them into the following categories:
      - Which areas are in full, partial, or noncompliance?
      - What can you quickly make compliant?
      - Do you need an action plan?

    If you need to develop a plan, do it during the third month.



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