R3 Report Issue 31: New and Revised Performance Improvement Accreditation Standards
Effective January 1, 2022, the Performance Improvement accreditation standards for ambulatory care, behavioral health care and human services, critical access hospitals, home care, hospitals, laboratories, nursing care centers, and office-based surgery practices will include several revisions. There will be one new standard with two elements of performance (EPs) and one new element of performance added to an existing standard. Introduction of the new standard and EPs has resulted in revisions to other existing standards and EPs to reinforce the connection between all the performance improvement requirements. These proposed revisions aim to strengthen the link between leadership priorities and goal setting and planning organizational quality assessment and performance improvement efforts. In addition, the proposed revisions encourage use of improvement tools or methodologies to achieve and sustain improved performance.
The Joint Commission evaluated literature, reviewed compliance data, and reviewed ORYX and other publicly available quality measures to determine how health care organizations are using performance data and performance improvement tools and strategies. Two common themes emerged among organizations with successful improvement programs:
- They adopted an established improvement methodology and used the associated tools in their efforts.
- They developed and maintained relevant and manageable plans for monitoring quality and prioritizing improvement initiatives. Organizational leaders play a critical role in the success of performance improvement efforts. Planning is key to harnessing the power of data. Deciding what data is important for the organization to monitor and how frequently, along with recognizing when the data is suggesting further action is an important responsibility for any leadership team. Useful data are analyzed and presented in an effective way that makes it easy for leaders to recognize potential performance concerns that require action. An example of available, ready-to-use data can be found in The Joint Commission’s DASH™ initiative (Data Analytics for Safe Healthcare) in the Accelerate PI™ tool and the SAFER™ Dashboard. Tools like these help identify risk areas and support organizational efforts to focus on the most critical issues impacting patient safety and the quality of care.
The prepublication version of the performance improvement standards will be available online until December 31, 2021. After January 1, 2022, please access the new requirements in the E-dition or standards manual.