Joint Commission readiness

Improve the focus of your PPR

After reading this article, you will be able to:

• Identify strategies for conducting a focused PPR

The Periodic Performance Review (PPR) is an annual self-assessment process designed to enhance Joint Commission readiness. However, organizations often make the mistake of scoring their electronic surveys so harshly that they end up with numerous noncompliant standards. This leads to the initiation of cumbersome, complex action plans that are difficult to fulfill. 

It is more helpful to focus on standards that put your organization at the highest risk of failure to achieve/maintain accreditation. Here are some suggestions that will help you conduct a more efficient, helpful PPR:

• Don’t go through the entire electronic PPR every year. Use your previous year’s PPR as a baseline and incorporate assessment of new or changed standards.
• Determine priority standards on which to focus and develop a realistic, attainable measure of success (MOS). 
• Remember that surveyors will use the information from your MOS to assess whether your organization is realistically working toward compliance.
• When reviewing new or changed standards, evaluate the processes already in place. Decide whether each process is in compliance, needs revision, or should be replaced with a new process. Do not automatically establish new processes if current ones are adequate.
• Focus on keeping things simple. Reduce rather than increase the number of steps needed to maintain or achieve compliance. 
• If your organization uses an on-site PPR instead of an electronic submission, be sure to ask the surveyor about ways to achieve and maintain compliance. Use the surveyor’s presence as an opportunity to learn.

Reference

Bielanski, G. (2010). “Issues surrounding the PPR.” Briefings on The Joint Commission.