Periodic Performance Review
George Mason UniversityCollege of Nursing and Health ScienceRegulatory Requirements for Health SystemsSummer 2004
Used with Permission
PPR is Elementary . . .
Shifts emphasis to a more continuous accreditation process by incorporating an additional form of evaluation
Uses the extranet to ensure efficiency
Creates an environment for educational opportunities
Is an accreditation participation requirement Must be completed between the 15th and 18th month
point – no on-site review Includes HCO self-evaluation of all applicable
standards, and development of corrective action plans for any standard evaluated as noncompliant
Involves telephone interaction between the HCO and the Joint Commission for review and approval of corrective action plans
Will not impact accreditation status, if HCO has an approved corrective action plan
PPR . . .
For each non-compliant standard the HCO will:
• Describe the planned action for each Element of Performance marked as partial or not compliant
• Develop a measure of success
PPR requires a Corrective Action Plan
A numerical or other quantitative measure usually related to an audit that validates that an action was
effective and sustained
Measure of Success defined as . . .
At the triennial survey, focus is on validating the implementation of corrective action plans
Surveyor asks for data related to the measure of success for each corrective action plan
Track record requirements remain in effect
Linkage between the PPR and On-Site Survey
Periodic Performance Review for ABC Hospital
Periodic Performance Review for ABC Hospital
Periodic Performance Review for ABC Hospital
Compliant
Not Compliant
Not Applicable
Standards will be shown as:
Periodic Performance Review for ABC Hospital
Periodic Performance Review for ABC Hospital
Periodic Performance Review for ABC Hospital
Periodic Performance Review for ABC Hospital
Periodic Performance Review for ABC Hospital
Uses the same tool employed by the surveyors
Increases intra-cycle interaction with JCAHO
Facilitates continuous operational improvement
Helps the HCO in quest for 100% compliance, 100% of the time
Benefits of Periodic Performance Review
Sources• Blomme, Jane (2002) ppt. Shared Visions – New
Pathways: Sharpening the focus of the accreditation process on care systems critical to the safety and quality of care. Joint Commission on Accreditation of Health Care Organizations.
• Massaro, Russ (May 2003) ppt. Executive Briefings, JCAHO Shared Visions—New Pathways: 2004 Accreditation Process, Joint Commission on Accreditation of Health Care Organizations.
• SMART: Staff Maintaining Accreditation Readiness Together (2003) ppt. Shared Visions – New Pathways: Update on the Survey of the Future. Inova Health System.
Top Related