The PPR is a new form of evaluation conducted by the organization to assess its level of compliance with standards. This comprehensive, self-directed review provides the framework for continuous standards compliance and focuses on the critical systems and processes that affect patient care and safety. By conducting the PPR annually, organizations can self-evaluate their compliance with all Accreditation Participation Requirements, Standards and Evidence of Performance; develop plans of action to address any identified opportunities for improvement; and implement those plans to improve care.
JCAHO requires that physicians at accredited hospitals be involved in the self-assessment component of the PPR and in developing plans of action. Each hospital must make its own determinations about how involved hospitalists and other physicians are with the PPR. JCAHO recognizes that hospitalists have limited time for performance improvement activities, but believes that their participation is crucial because of their commitment to providing care that results in positive outcomes for patients and reduces risk.
Patient Tracer Methodology and PPR in 2006
As part of changes to the accreditation process, JCAHO will shift from scheduled to unannounced on-site surveys. The transition to unannounced surveys began this year:
- To enhance the credibility of the accreditation process by ensuring that surveyors observe organization performance under normal circumstances;
- To help healthcare organizations focus on providing safe, high quality care at all times, and not just when preparing for survey;
- To reduce the unnecessary costs that healthcare organizations incur to prepare for survey; and
- To address public concerns that JCAHO receive an accurate reflection of the quality and safety of care.
The new accreditation process supports this transition by considering the information generated by the PPR. Organizations will be able to update the PPR, available on each organization’s extranet site, annually to support continuous performance improvement efforts.
JCAHO conducted pilot testing of the unannounced survey process in volunteer organizations during 2004 and 2005, giving its staff insight into real-life issues and concerns at accreditation organizations. JCAHO also worked closely with its various advisory groups, accredited organizations and other stakeholder groups to gain their input and smooth the transition to unannounced surveys.
Conclusion
The participation of the hospitalist in the JCAHO accreditation process is dependent upon common interests in improving healthcare quality and safety. JCAHO accreditation can be used to help the hospitalist and healthcare organizations meet their goals and responsibilities to individual patients. Accreditation activities can help to focus physician involvement in patient safety and other important areas, thus bringing increased relevance to the accreditation process.
In conclusion, the importance of the hospitalist to the JCAHO accreditation process on a continuous basis, not just during the on-site survey, is crucial. TH
Dr. Jacott was appointed a special advisor for professional relations to the Joint Commission in January 2002. As special advisor for professional relations, Dr. Jacott serves as the Joint Commission’s liaison to SHM.