1. Periodic Performance Review George Mason University College of Nursing and Health Science Regulatory Requirements for Health Systems Summer 2004 Used with Permission

2. 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

3. 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...

4. 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

5. 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...

6. 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

7. Periodic Performance Review for ABC Hospital

8. Periodic Performance Review for ABC Hospital

9. Periodic Performance Review for ABC Hospital

10. Compliant Not Compliant Not Applicable Standards will be shown as:

11. Periodic Performance Review for ABC Hospital

12. Periodic Performance Review for ABC Hospital

13. Periodic Performance Review for ABC Hospital

14. Periodic Performance Review for ABC Hospital

15. Periodic Performance Review for ABC Hospital

16. 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

17. 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.