Periodic Performance Review
Joseph L. Cappiello
Vice President for Accreditation Field Operations
By design, what we had hoped for was to allow organizations to think about and respond to continuous compliance on an ongoing basis. What that would do in our mind as we planned this out was to eliminate this issue that we hear about consistently over the years and that’s the issue of ramp-up, that there is this period of 12 months or eight months prior to the triennial survey that there is a frenzy of activity on organizations’ part to prepare for the upcoming survey. That really sort of drains staff away from provisions of care and ongoing management, it was expensive, consultants were brought in, the usual sort of array of activities to prepare for the triennial survey. What we had hoped to do with the use of the periodic performance review was really to interdict that and rather than have this steep ramp-up, to flatten that out to a more continuous process.
Feedback
Now here is the feedback that we’re getting from the organizations as they’ve gone through the periodic performance review. They’re telling us that they are understanding what real compliance with standards means. They’re able to integrate that into daily operations so that the standards become a living management tool. And if you think of the standards as nothing more really than a risk reduction strategy, to be able to apply that to these organizations day in and day out is a wonderful benefit that we’re hearing about and getting great reinforcement about from our accredited organizations.
Completing the PPR
My suggestion would be that the broader range of people that you have engaged in the PPR, the periodic performance review evaluation, the better the organization is. Now, that may take a little longer, a little more time for that sort of inclusion, but I think the benefit to expose more staff to standards, get input from more staff, particularly the medical staff, will reap great benefits for the organization.
Password protected
The periodic performance review is password protected, and it is really the decision of the organization as to who should be given that password or who can be given that password. Once that password is given out, whoever has the password can access the periodic performance review. Now, I would give some caution to organizations about how widespread they wish to give that password out. That means that anyone with the password can go in and manipulate or change the scoring of the periodic performance review, so one should be cautious about controlled access. And I think you would do that just as you would with any other important piece of information. It should be managed on sort of a need to access or a need to know basis.
Continuous access as of January 18, 2005
When we initially designed it, we really didn’t conceptualize that there would be a desire to have ongoing, almost daily or weekly, access to the tool itself, so we had a time frame in which the organization could access the tool, input into the tool and then close the tool out. What we have now done is, starting in January of 2005, all of the accredited organizations will have continuous access to their periodic performance review.
Telephone conference call
Now, another great advantage is the fact that they have now access as they have completed their periodic performance review to make contact with our Standards Interpretation Group back here at the Joint Commission in a scheduled, personal conversation between the Standards Interpretation Group and the organization to review their periodic performance review tool, but more importantly, to review with the Standards Interpretation Group their required Plans of Action. Whenever there is a standard that is not compliant, we’re going to ask you, we’re going to ask the accredited organization, to construct a Plan of Action on how to come into compliance with the standard. Rather than try and do this on your own, you can do this with the benefit of the expertise from the Standards Interpretation Group. And what that also then does, once that Plan of Action is approved by the Standards Interpretation Group, it cannot be challenged by the surveyors on site. This is an official approval of your plan and how you’re going to come into compliance. We can also work with you if there are standards that are scored noncompliant by you or evaluated noncompliant. Some of them have something called the Measure of Success, and we can work with you to ensure that the Measure of Success that you’re going to build is adequate to demonstrate compliance with the standard.
Who should participate on the call?
At the other end of the call, what we would like to see just for the sake of being able to have a repartee, a give and take, probably no more than two staff members who are directly responsible for leading questions and responses back to the Standards Interpretation Group. However, we really encourage as many staff at the organization level as possible to be listeners on the call, so they may often do it in a conference room where there are leaders of the call, one or two leaders of the call, from the organization, but they have really quite a packed room with department heads and staff members, et cetera to listen to the dialogue because it really is a great learning experience.
Conference call length
We’re finding that the length of the call varies based on two things. Number one, the first thing, the first variable, I should say, is the number of noncompliant standards that the organization has identified. Obviously, the more noncompliant standards there are, the more Plans of Action, potential Measures of Success that need to be reviewed, so that would lengthen the call. The other factor that contributes to the length of the call is the number of questions that the organization may have regarding the accreditation participation requirements or the National Patient Safety Goals, those sorts of things, or just consultative questions that they may ask in the midst of reviewing their noncompliant standards. So the average that we have seen has probably been as short as a half hour or 45 minutes and as long as two to two and one half hours.
During the on-site survey
Certainly, the surveyors are going to want to see that you have done what you said you’re going to do, so you’ve created a Plan of Action, which they will not challenge because that’s already been accepted officially by the Standards Interpretation Group, but what they will look for is execution against that plan of action: Did you do what you said you were going to do? And have you been successful in it?
Changes in 2006
In 2006, when we move to fully unannounced surveys, that certainly is going to impact the periodic performance review. And the methodology that we have decided upon is there will be some form of annual submission of the periodic performance review. Whether that is the full PPR that’s required each year, whether that is components or selected standards, we haven’t worked the particulars out yet. And in fact, we will work with the field, get feedback from the field, and together we will develop a methodology in which we have some ongoing annual contact between the health care organizations and the Joint Commission in 2006.