JCAHO Revises Periodic Performance Options to Offer a Verbal On-Site Survey

Effective January 1, 2004, the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO") implemented significant changes to its accreditation process by unveiling its new process "Shared Visions - New Pathways." This new process focuses on assessing a health care facility's operations based on achievement of defined quality of care and patient safety goals. JCAHO's goal in revising the accreditation process was to shift the focus of JCAHO accreditation away from achieving a certain survey score and toward providing quality health care.

One key feature of the revised process is the Periodic Performance Review ("PPR"), which will take place 18 months following the triennial accreditation survey. The PPR requires the accredited health care facility to evaluate its operations to identify and address issues of concern and compliance with JCAHO standards. Through the PPR process, facilities develop a Plan of Action and Measures of Success ("MOS") for addressing and resolving problem areas.

JCAHO accredited health care facilities are required to participate in one of the four available JCAHO PPR options. The original PPR options did not include the newly unveiled verbal on-site survey option, which is described in the following overview of PPR options.

1. Option 1: Full PPR Survey. The health care facility undergoes an organizational review of standards compliance using JCAHO's automated review tool, customized for the facility.
   • The health care facility develops and submits to JCAHO a Plan of Action and MOS for issues identified during the survey within 30 days of the survey.
   • The health care facility participates in a telephone conference review session with the JCAHO Standards Interpretation Group (the "SIG"). The SIG reviews and approves the facility's Plan of Action.
   • At the time of the triennial survey, JCAHO will review the PPR Plan of Action.
2. Option 2: Self-Assessment. The health care facility conducts a self-assessment of its compliance with JCAHO standards.
   • The health care facility attests that, after careful consideration with legal counsel, it has decided not to participate in the full PPR survey and will conduct its own self-assessment.
   • The healthcare facility attests that it has completed a self-assessment and has developed a Plan of Action and MOS.
   • The health care facility may choose to discuss standards-related issues with the SIG without identifying specific information obtained during the self-assessment. However, some of the assessment information will need to be provided to the SIG so that the questions may be properly addressed.
   • At the time of the triennial survey, JCAHO will review the PPR Plan of Action.
3. Option 3: JCAHO On-Site Survey. The health care facility undergoes a JCAHO on-site survey that is one-third the length of the triennial survey.
   • The health care facility attests that, after careful consideration with legal counsel, it has decided not to participate in the full PPR survey but will participate in a JCAHO on-site survey.
   • The health care facility is charged a fee (one-third of the cost of a full survey).
   • The health care facility develops and submits to JCAHO a Plan of Action and MOS for issues identified during the survey within 30 days of the survey.
   • The health care facility participates in a telephone conference review session with the SIG. The SIG approves the facility's Plan of Action.
   • At the time of the triennial survey, JCAHO will review the PPR Plan of Action.
4. Option 4: Verbal JCAHO On-Site Survey (newly developed option). The health care facility undergoes a JCAHO on-site survey with all survey findings verbally conveyed to the health care facility.
   • The health care facility attests that, after careful consideration with legal counsel, it has decided not to participate in the full PPR survey but will participate in a JCAHO on-site verbal survey.
   • The health care facility is charged a fee (one-third of the cost of a full survey).
   • At the time of the triennial survey, JCAHO will review the results of the PPR survey.

Before a health care facility makes a decision concerning whether to undergo a full PPR or one of the other options described above, the health care facility should consult with legal counsel to assess the potential discoverability of the PPR documents as well as protection of such information under Federal and Wisconsin confidentiality and peer review laws. Please do not hesitate to contact the Reinhart Health Care Department if we may further assist you concerning this matter.