June Newsletter: Joint Commission Behavioral Healthcare Update

All accredited organizations have now become accustomed to completing the annual Periodic Performance Review (PPR) required by TJC since 2004. The PPR can be a very valuable tool for keeping your organization in a state of continuous survey readiness. It's the most thorough self assessment you can do to determine your compliance with TJC standards. Once completed, the PPR is the foundation for developing an action plan for full compliance and survey readiness. The PPR is particularly critical for your organization as you approach your anticipated triennial survey.

Some organizations get more value than others from completing their PPR. Over the past few years, we have seen some common "PPR Pitfalls" that organizations can fall into. Try to avoid these when tackling you next PPR:

Pitfall # 1: The "We do that!" Syndrome:
This is when managers sit around the conference table, read the standard and say: "We do that." They don't actually use any observations or data but rather assume compliance. This is risky. Make sure that before you conclude "We do that," you go out and check to see if it's actually being done according to the requirements of the standard.
For example, you know your staff does client education. But, before you score yourself fully compliant, check and see if your clinical records would show that this education is being done.

Pitfall # 2: The "We have a policy on that!" Syndrome:
This is when an organization thinks that because it has a policy in place related to the standard, then it is in full compliance with the standard. Remember, the PPR is asking you to assess not just the existence of a policy but rather implementation of that policy on an ongoing basis. You may have the perfect pain management policy on paper but is the staff consistently implementing the process according to your policy?

Pitfall # 3: The "We've never been cited on that in the past!" Syndrome:
This is when an organization reviews a standard and concludes that they must be in compliance because they have not been cited on it in previous surveys. Don't assume this! The surveyor may simply have missed it. Or, you may have been in compliance at that time but now your performance on that process has changed. Go out and check it out to see how the process is performing today.
Case in point: one organization recently received an RFI because their glucometers did not have two levels of control (PC.16.50 in BH Manual; WT.04.01.01 in Hospital Manual.) They had scored themselves compliant on their PPR but no one had actually checked the glucometers that were being used. Turns out that someone had replaced the previous glucometers (which had two levels of control) with a new model that had only one level of control. Lesson learned: go out and see for yourself.

PPR Strategies

We have found that organizations that use a planful and organized approach to completing their PPR go through their surveys with greater confidence and better outcomes. When working with organizations on their PPRs, we help them organize the effort into the following steps:

Remember, you are not required to share your PPR with the surveyors during your survey. They cannot ask to see your PPR. They can only ask to see the Measure of Success (MOS) data. This is the data you need to collect for any standards/elements of performance that you scored as non-compliant and that required a Measure of Success (designated by an "M" on the PPR.)

It's a guarantee that if you are thorough and rigorous in completing your PPR, you will have a smoother, more successful survey experience. And, who wouldn't welcome that?