Options to the full Periodic Performance Review
Joseph L. Cappiello
Vice President for Accreditation Field Operations
We developed options based on feedback from the field and concerns from the field that in some states the laws of those states do not provide enough protection for the information that would be developed, that we would expect to be developed, internally and transmitted to the Joint Commission. In those states, that information may be discoverable in court.
Option 1
Number one, they have to notify the Joint Commission that they have selected option one. We will give them instruction as to what that means. And what we’re going to tell them is the following: that they must complete a thorough and complete self-assessment of all the standards. Secondly, for any standard that they find not in compliance, they must perform or construct a Plan of Action and, where required, based on the standard, a Measure of Success. They must then attest to the fact that they have completed those activities and submit that attestation to the Joint Commission. When the surveyors arrive on-site to an accredited organization that has selected Option 1, the surveyors will not ask for their self-assessment, the surveyors will not ask for their Plan of Action, but the surveyors will inquire about Measures of Success, if they are applicable, and they would want to review those Measures of Success for completeness.
Option 2
First of all, there is essentially no communication regarding the periodic performance review that moves from the accredited organization to the Joint Commission. This is an on-site review of standards compliance. In other words, we will dispatch a surveyor to that organization for a period of time that is usually one-third the number of surveyor days that they had at their last triennial. Let me give you a quick example. If they had two surveyors for three days, that would be six surveyor days; we would dispatch a surveyor for one-third of that time, or two days. And during those two days, the surveyor would do a standards-based review, sort of a mini-survey, if you will. Any noncompliant standards that are identified by the surveyor, the organization then is required to develop Plan of Action and Measures of Success, if applicable, to those noncompliant standards. There is also a requirement ¾ a requirement that they must engage in a dialogue with the Standards Interpretation Group, the scheduled interview, to review those noncompliant standards and the Plan of Action and Measures of Success for those noncompliant standards.
Option 3
As in Option 2, we require the organization to complete a comprehensive self-assessment of all standards. Whether they use the periodic performance review tool or something like that or not, it’s optional to them, but we do require that they go through all the standards comprehensively to identify their compliance. Secondly, as in option two, a surveyor will be dispatched for a limited survey. Usually the same formula applies: one-third of the surveyor days at the triennial are used for the surveyor to come on-site; six surveyor days at the triennial, two surveyor days as part of option three. At the completion of option three, there is no written material left behind by the surveyor; only a verbal report of compliance is given to the organization. And the other difference between Option 2 and Option 3 is in Option 2 the Standards Interpretation call is required; it is not required as part of Option 3.