Periodic Performance Review (PPR) is an important component of The Joint Commission accreditation process. Its purpose is to support continuous compliance with Joint Commission standards in the hospital.
In a PPR, the hospital evaluates its own compliance with applicable standards, Accreditation Participation Requirements (APRs), and National Patient Safety Goals (NPSGs), and develops a plan of action for identified areas of noncompliance. A plan of action is a description of how the organization plans to bring into compliance any standard and associated elements of performance (EPs) that are out of compliance. The plan of action should include a description of the action to be taken and target dates for correcting the problem.
Completing the PPR is an APR for hospitals. Each hospital must submit a completed full PPR to The Joint Commission or chose option 1, option 2, or option 3. The PPR options were developed in response to concerns about legal disclosure of PPR information shared with The Joint Commission. The hospital can change its PPR type annually.
From January 1, 2006, PPRs are required annually. The due date for PPRs is the date of the hospital’s last full survey. For example, if the hospital’s last full survey ended on August 1, 2007, its next annual PPR will be due on August 1, 2008.
Full PPR
In the full PPR, the hospital assesses and scores compliance with the standards and the EPs. Then it develops a plan of action and measure of success (MOS), if required, to address each EP scored as “partial or insufficient compliance” within any standards found to be “not compliant.” The hospital then submits the PPR data and plan of action(s) to The Joint Commission for approval. The surveyors review any required MOS during the full survey.
The Options
In Option 1, the hospital completes the PPR like the full PPR but does not submit the data to The Joint Commission. The surveyors review any required MOS during the full survey.
The hospitals that choose Options 2 and 3 undergo a limited announced survey. The survey is approximately one third the length of the full survey. In Option 2, the surveyors leave a written report of the findings with the hospital. However, in Option 3 there is no written report and the findings are delivered orally. In Option 2, the surveyors will review any required MOS during the full survey. However, in Option 3 there is no review of MOS data during the full survey.
The accreditation decision of the hospital is not affected by the results of its PPR. There will be an effect on the accreditation decisioÂn if a PPR is not submitted within 30 days of the due date or if through the PPR process an immediate threat to life situation is identified and a special survey is required.
Tracer Methodology
Tracer methodology is another important component of The Joint Commission accreditation process. During the on-site survey, it is used to evaluate an organization’s compliance with the standards. In tracers the surveyor follows a patient through his or her care experience while at the hospital. It is used to assess the hospital’s compliance with the applicable standards and its systems of providing care and services. It includes a review of patient records, interviewing the staff, and evaluating policies and procedures.
The number of tracers completed depends on the length of the survey and the size of the hospital. There are about 11 to 14 tracers during a 3-to-5-day hospital survey with a team of three surveyors. Each tracer usually lasts about 2 to 3 hours.
Example of a Tracer
In the care of a cardiology patient at the hospital, the surveyor will trace the path the patient takes as he or she enters the hospital through the emergency department. The emergency department staff may be asked about fire prevention, use of the fire alarm box, how they report a fire, or what they will do in case of a fire. The surveyor might also ask to see the room where the patient was treated and note identifying numbers on the ECG monitor in the room. Later, the surveyor could ask to see the maintenance records for the ECG monitor. The surveyor might evaluate the staff’s knowledge about the emergency shutoff of gases. An infusion pump in the coronary care unit (CCU) where the patient stayed might prompt the surveyor to ask the nurse in the CCU to demonstrate how this infusion pump will not free flow. The physiological monitoring system used on the patient may prompt the surveyor to ask the nurse, “Can you hear all the clinical alarms in this area?” or “Can you hear all the clinical alarms when the patient room door is closed?” During the course of the tracer an ECG technician might say that when he or she plugged in the ECG machine for taking the patient’s ECG in CCU it sparked. This may lead the surveyor to focus on how well the staff implements the medical equipment management plan, and may ask about the acquisition/selection procedures, maintenance records, and equipment replacement procedures.
Arif Subhan, MS, CCE, is a senior clinical engineer, Masterplan, Chatsworth, Calif, and chair, education committee, ACCE. For more information, contact .