Now in effect: Performance Improvement requirement clarification

A revision to Performance Improvement (PI) standard PI.01.01.01, Element of Performance (EP) 4, is going into effect immediately for hospitals, critical access hospitals, ambulatory care and office-based surgery practices.

This change was made after healthcare organizations expressed confusion with the requirement, which directs them to collect data on significant discrepancies between preoperative and postoperative diagnoses.

The revision provides:

• Details and examples to further clarify the intent for this data collection requirement and how the data can be used in an organization’s performance improvement efforts regarding diagnostic errors.
• Clarifies that the organization’s medical staff determine which unexpected postoperative diagnoses are clinically significant.

View the prepublication standards. Questions may be directed to the Department of Standards and Survey Methods.