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• Breast Cancer quality measures next on the Joint Commission’s list

  The Joint Commission Division of Quality and Research is now focusing on developing quality measures to assess and improve care for breast cancer patients undergoing chemotherapy in an ambulatory setting, according to an official announcement from The Joint Commission. The National Philanthropic Trust's Breast Cancer Fund is providing funds to the Oncology Nursing Society Foundation (ONS) to develop this set of quality measures. Testing will take place throughout the year, and public comment on the Breast Cancer Care (BCC) quality measures is being accepted through March 19.

• Two National Patient Safety Goals receive minor changes

  The Joint Commission has made minor changes to two National Patient Safety Goals (NPSG), according to an official statement on their Web site. The changes will be effective immediately and affect the NPSGs for ambulatory care, critical access hospitals, hospitals and office-based surgery organizations. The corrections will appear in the July 2010 update to the e-dition as well as in the printed manual.

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. To learn more visit The Center for Healthcare Accreditation.

  Gayle Bielanski
  RN, BS, CPHQ
  

  Issues surrounding the PPR
  

  Part 2 of 3
  

  Once an organization has determined the limited number of priority standards in which to focus on for the year, the developed MOS should be realistic and attainable. It must be kept in mind that the MOS, and the compliance to the MOS, can be used by the surveyor during the next triennial survey.

• AHAP continues contest, offers free registration to conference in Las Vegas

  The Association for Healthcare Accreditation Professionals (AHAP) will hold a series of drawings for free registrations to its annual conference in Las Vegas, which will be held on May 6-7, 2010. The contest will pick a winner among eligible AHAP members at the end of March and April. The February winner has already been chosen.

• AHCJ requests better reporting from The Joint Commission’s Web site

  The Association of Health Care Journalists (AHCJ) recently wrote a letter to the Joint Commission's president and CEO, Mark R. Chassin, MD, suggesting the hospital accreditation organization make vast improvements to their Quality Check Web site, according to AHCJ's official Web site. The Joint Commission's Quality Check Web site is where the public can go to find quality information about their local hospital. However, AHCJ's Right-to-Know committee identified several problem areas on the site.

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. To learn more visit The Center for Healthcare Accreditation.

  Gayle Bielanski
  RN, BS, CPHQ

  Issues surrounding the PPR
  

  Part 1 of 3
  

  The Periodic Performance Review (PPR) is an annual self-assessment process aimed at supporting continuous accreditation readiness and performance improvement activities required by The Joint Commission. There are traps that many organizations can fall into when scoring the electronic assessment. One pitfall is to score too harshly and end up with a large number of non-compliant standards that must then have Measures of Success (MOS) demonstrated to show compliance. There have been organizations that have scored 30 to 40 standards noncompliant, which resulted in an extremely complex and difficult action plan in which to comply.

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