Periodic Performance Review

George Mason UniversityCollege of Nursing and Health ScienceRegulatory Requirements for Health SystemsSummer 2004

Used with Permission

PPR is Elementary . . .

Shifts emphasis to a more continuous accreditation process by incorporating an additional form of evaluation

Uses the extranet to ensure efficiency

Creates an environment for educational opportunities

Is an accreditation participation requirement Must be completed between the 15th and 18th month

point – no on-site review Includes HCO self-evaluation of all applicable

standards, and development of corrective action plans for any standard evaluated as noncompliant

Involves telephone interaction between the HCO and the Joint Commission for review and approval of corrective action plans

Will not impact accreditation status, if HCO has an approved corrective action plan

PPR . . .

For each non-compliant standard the HCO will:

• Describe the planned action for each Element of Performance marked as partial or not compliant

• Develop a measure of success

PPR requires a Corrective Action Plan

A numerical or other quantitative measure usually related to an audit that validates that an action was

effective and sustained

Measure of Success defined as . . .

At the triennial survey, focus is on validating the implementation of corrective action plans

Surveyor asks for data related to the measure of success for each corrective action plan

Track record requirements remain in effect

Linkage between the PPR and On-Site Survey

Periodic Performance Review for ABC Hospital

Periodic Performance Review for ABC Hospital

Periodic Performance Review for ABC Hospital

Compliant

Not Compliant

Not Applicable

Standards will be shown as:

Periodic Performance Review for ABC Hospital

Periodic Performance Review for ABC Hospital

Periodic Performance Review for ABC Hospital

Periodic Performance Review for ABC Hospital

Periodic Performance Review for ABC Hospital

Uses the same tool employed by the surveyors

Increases intra-cycle interaction with JCAHO

Facilitates continuous operational improvement

Helps the HCO in quest for 100% compliance, 100% of the time

Benefits of Periodic Performance Review

Sources• Blomme, Jane (2002) ppt. Shared Visions – New

Pathways: Sharpening the focus of the accreditation process on care systems critical to the safety and quality of care. Joint Commission on Accreditation of Health Care Organizations.

• Massaro, Russ (May 2003) ppt. Executive Briefings, JCAHO Shared Visions—New Pathways: 2004 Accreditation Process, Joint Commission on Accreditation of Health Care Organizations.

• SMART: Staff Maintaining Accreditation Readiness Together (2003) ppt. Shared Visions – New Pathways: Update on the Survey of the Future. Inova Health System.