The Periodic Performance Review is a compliance assessment tool designed to help organizations with their continuous monitoring of performance and performance improvement activities. The PPR provides the framework for continuous standards compliance and focuses on the critical systems and processes that affect patient care and safety. There are four ways that an organization can complete the PPR process: the full PPR or Options 1, 2 or 3. The options were created in response to concerns about legal disclosure of PPR information shared with The Joint Commission.
Benefits of the PPR and options
Both the full PPR and the options facilitate a continuous accreditation process by incorporating an additional form of evaluation. The full PPR and the Option 2 survey have the additional benefit of helping to ensure consistency in the accreditation process, since approved Plans of Action cannot be challenged during the survey, and the scoring methodology for the PPR is the same as that used by surveyors during the on-site survey.
Full PPR
- Each year, the organization uses the automated PPR tool to assess and score compliance with the Elements of Performance for each applicable standard.
- The organization creates a Plan of Action addressing each EP scored as partial or insufficient compliance within any standards found not compliant.
- The organization identifies Measures of Success (as indicated) for each EP scored as partial or insufficient compliance within any standards scored as not compliant.
- The organization submits its PPR to The Joint Commission annually.
Joint Commission staff reviews all PPR submissions. Approval of Plans of Action can only occur during a conference call with the Standards Interpretation Group.
Option 1
- The organization uses the PPR tool to annually affirm that legal counsel advises the organization not to participate in the full PPR. Instead, the organization completes a PPR and Plan of Action and identifies appropriate MOS (as indicated).
- The organization may use the PPR tool to score compliance, and can print and view standards and EPs to conduct its assessment on paper.
- The organization affirms that it has completed an assessment of its compliance with applicable EPs and developed Plans of Action and MOS, if needed, but does not submit these data to The Joint Commission when the affirmation is submitted.
- The organization can submit standards-related issues in the PPR tool for telephone discussion with Joint Commission staff. No approvals are given for Option 1 PPRs.
Option 2
- The organization uses the PPR tool to annually attest that, after careful consideration with legal counsel, it has decided not to participate in the full PPR and instead will undergo a limited PPR survey. The organization can choose a full PPR survey without legal consideration. (Fees will be charged.)
- The organization submits the PPR tool again within 30 days of the survey.
- his submission addresses not compliant standards, choice of a conference call, and topics for discussion with Joint Commission staff.
- The organization creates a Plan of Action and any required MOS for each standard scored not compliant and submits data to The Joint Commission via the PPR tool within 30 days of survey.
- Joint Commission staff reviews the submitted plans and MOS. Approval can only be given during a conference call with the Standards Interpretation Group.
Option 3
- The organization uses the PPR tool to annually attest that after careful consideration with legal counsel, it has decided not to participate in the full PPR and instead will undergo either a limited survey or a full-length PPR survey. (Fees will be charged.)
- Unlike Option 2, Option 3 stipulates that no written report of findings will be left at the organization. The surveyor delivers an oral report of findings at the closing conference of the on-site survey. No findings are transmitted to The Joint Commission.
- The organization submits the PPR tool again within 30 days of the survey. This submission addresses the choice of a conference call and any topics for discussion with Joint Commission staff.
If an organization selects the full PPR, Option 1 or Option 2, surveyors will ask to see MOS data at the time of the full survey. It’s important to note that an organization’s accreditation decision is not affected by the results of its PPR.
For more information about the PPR, visit The Joint Commission website at www.jointcommission.org. Accredited organizations may also visit their secure site on The Joint Commission Connect extranet, review their accreditation manual, or contact their account representative.
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