Periodic Performance Review

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Periodic Performance Review
Used with Permission

• George Mason University
• College of Nursing and Health Science
• Regulatory Requirements for Health Systems
• Summer 2004

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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

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PPR . . .

• 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

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PPR requires a Corrective Action Plan

• 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

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Measure of Success defined as . . .
A numerical or other quantitative measure usually
related to an audit that validates that an action
was effective and sustained
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Linkage between the PPR and On-Site Survey

• 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

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Periodic Performance Review for ABC Hospital


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Periodic Performance Review for ABC Hospital

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Periodic Performance Review for ABC Hospital

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Standards will be shown as
Compliant
Not Compliant
Not Applicable
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Periodic Performance Review for ABC Hospital

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Periodic Performance Review for ABC Hospital

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Periodic Performance Review for ABC Hospital

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Periodic Performance Review for ABC Hospital

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Periodic Performance Review for ABC Hospital

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Benefits of Periodic Performance Review

• 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

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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 VisionsNew 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.