Organizations not affiliated with the Joint Commission produce products and sponsor education programs related to JCAHO accreditation. At times, the information provided in these products and programs is confusing, misleading, or inaccurate. The Fact on Fiction column identifies this misinformation with the intent of preventing confusion and correcting misperceptions in the field. This column is included in Perspectives on an “as needed” basis, whenever misleading or inaccurate information on JCAHO initiatives is published.
PPR Option 2
The September 8, 2003, edition of Modern Healthcare states in an article about the options to the Periodic
Performance Review or PPR (see October 2003 Perspectives, "JCAHO Offers Two Alternative Ways to Fulfill the Periodic Performance Review," for an explanation of the full PPR and options), “In the second alternative [option 2], a hospital concerned about admitting a deficiency would forgo the self-assessment process and submit to a one-day survey at the 18-month mark of the survey cycle.”
The on-site PPR survey under option 2 will not necessarily be a one-day survey. Rather, it will be one-third the usual length of the organization’s triennial survey. Therefore, if the organization’s full survey is nine days, the PPR survey at its mid-point will be one-third of nine days or approximately three days.
National Patient Safety Goals
For 2004, JCAHO made an addition to National Patient Safety Goal 2b, adding “critical test results” to the items for which a verification read-back process is required (see September 2003 Perspectives, "2004 JCAHO National Patient Safety Goals Approved"). In an article about National Patient Safety Goal 2b, the September 1, 2003, issue of Inside the Joint Commission makes the following statement: “…under the newly revised patient safety goals, the onus to verify an order will be on the physicians, not the nurses… And that will require a policy rewrite.”
“This statement is incorrect,” says Richard Croteau, M.D., JCAHO’s executive director of strategic initiatives. “The responsibility for verification lies with the person receiving the order or test results. In the case of orders, it is usually the physician giving the order, so the person receiving the order would be expected to write it down and read it back for verification. In the case of test results, the information might flow in the opposite direction, that is, from the nurse to the doctor. In that case, the physician is expected to write it down and read it back to verify its accuracy.”
Croteau goes on to explain the term critical test results: “The term critical test results is defined by the individual health care organization and will typically include ‘stat’ tests, ‘panic value’ reports, and other results that require urgent response. It is not limited to just laboratory results. For most organizations, this will include all laboratory and imaging test results reported verbally or by telephone. If a subset of ‘critical test results’ is not defined by the organization, surveyors will consider all verbal or telephone reports of laboratory tests and imaging studies to be ‘critical.’”
Quality Report
In the June 23, 2003, issue of Inside the Joint Commission, an article about JCAHO’s new Quality Report discusses how the reports will include a side-by-side comparison of an organization’s performance in National Patient Safety Goals, quality improvement goals, and core measures against the performance of other organizations of the same type.
The article raises the following point: “It is not known if data will indicate hospital size… which could spell trouble for smaller, more rural facilities.” The article goes on to state that a comparison may not be statistically fair between a small or more specialized hospital that may only treat four heart attack victims in one year and a larger hospital that may treat hundreds of heart attack victims in the same year.
John Cullinan, JCAHO’s director of electronic health products, information technology department, reports that there are no current plans to group organizations by size or number of cases for purposes of comparison in the Quality Report. However, the issue of statistic significance will be addressed. “We will report [in the Quality Report] the percentage rate and number of cases for the measure for the period of time being reported,” Cullinan says. “Also, if the number of cases is very small so as not to be statistically representative (less than 25 cases), we will not do a comparative analysis for that measure.”