Periodic Performance Review


A periodic performance review (PPR) is a self-assessment of standards all of which are applicable to a health care organization. The Joint Commission of Healthcare Organization conducts triennial surveys of health care organizations. The PPR involves an annual assessment of an organization’s performance. The PPR show the organizations performance in relationship to the standards set forth by the Joint Commission.

The standards are measured by elements of performance. Some elements of performance require a simple response of yes or no while others require multiple possible responses (e.

g., compliant, partial, and noncompliant). The PPR helps determines and organizations readiness for an accreditation audit


An integral component in the Joint Commissions accreditation process, PPR promotes continuous standard compliance through ongoing internal monitoring. Beginning in January 2006, the Joint Commission expects organizations to conduct annual self-assessment against applicable Joint Commission standards, develop plans of action to address identified areas of non-compliance and identify measures of success in the identified problem areas to validate resolution.

At the mid-cycle point, the organization is expected to share information with the Joint Commission. The staff at the Joint Commission will work with the organization to refine its plan of action to assure that the corrective efforts are on target.

To address concerns about the potential discoverability of PPR information, particularly where it is shared with the Joint Commission, the Joint Commission has established three options to the full PPR, for accredited-health care organizations: Option One: The organization performs the full self-assessment, develops the plan of action and measures of success (MOS), but does not submit PPR data to the Joint Commission. At the time of the complete on-site survey, the organization provides its MOS to the Joint Commission surveyor team for assessment.

Option Two: The organization remains accountable for conducting a full self-assessment and developing plans of action and applicable MOS, but does not submit PPR data to the Joint Commission. The organization undergoes an on-site survey, which will be approximately one-third the length of a typical full on-site survey. The organization receives a report of the survey activities. Option Three: The organization remains accountable for conducting a full self-assessment and developing plans of action and applicable MOS, but does not submit PPR data to the Joint Commission.

The organization undergoes an on-site survey, as in Option Two, but no written documentation or written report of the survey is provided to the organization. Nightingale Community Hospital is completing a PPR to assess the readiness of the hospital for an upcoming accreditation by the Joint Commission. This analysis will include:

1. The current compliance status of the hospital.

2. Trends evident in the case study that may cause the organization to not be in compliance with regards of patient care as set forth by the Joint Commission. 3. A review of staffing of the hospital’s patient care unit with regards of the performance improvement standard by doing the following: a. An analysis of the data to determine the staffing patterns of the patient care unit. b. A plan to develop a staffing plan to minimize the number of falls in the patient care unit.


In reviewing the data of Nightingale Community hospital, there are a number of compliance standards the hospital will need to address to remain in compliance with the Joint Commission standards which fall into several broad accreditation functions

1) Environmental Care – the environment of care is made up of several areas in terms of patient care including the he building or space, including how it is arranged and the special features that protect patients, visitors, and staff, equipment used to support patient care or to safely operate the building or space, and people, including those who work within the hospital, patients, and anyone else who enters the environment, all of whom have a role in minimizing risks. The self-assessment noted deficiencies with interim life safety measures (ILSM) which refers to the health and safety measures that are put in place to protect the safety of patients, visitors, and staff who work in the hospital. Environmental factors that include signs and pathways to an egress point, fire protection systems including smoke detectors (specifically noted in the self-assessment), fire suppression, fire extinguishers and fire alarm systems, smoke barriers, emergency evacuation plans, in addition to many other items that contribute to the well-being and safety of occupants in the hospital or healthcare facility.

2) Nursing leadership – this specific deficiency noted out of compliance showed inconsistencies in nurses documentation and timeliness which affected morale

3) Record of Care – this compliance standard refers to all the data and information gathered about a patient from the moment he or she enters the hospital to the moment of discharge or transfer. The particular deficiency noted is verbal orders are not authenticated within 48 hours. This particular problem is noted under on several floors within the hospital

4) Life Safety – A particularly critical standard in terms of patient care that is crucial in terms of patient and staff safety. The self-assessment noted clutter in hallways and carts in the hallways as noted in the observations during the PPR rounds.

5) Information Management – this patient care standards refers to the whether the hospital has a written policy regarding the privacy, security and integrity of health information. The deficiency noted prohibited abbreviations found in nursing notes and or physician orders as noted in the chart review conducted the PPR rounds

6) Medication Management – this is an important component in palliative treatment of many diseases and conditions. To minimize harm, the hospital needs to develop an effective and safe medication system. The hospital deficiencies with this standard was noted in the staff interviews where it was shown nurses did not follow range order policy or could explain how this is executed. It was also noted the syringes were found unlabeled in the OR and Cath labs.

7) Provision of Care, Treatment and Services (PC) – these standards revolves around assessing patient needs and planning, providing and coordinating treatment and services. Several deficiencies noted in audit included day of procedure reassessment inconsistencies and absence of documented plan of anesthesia

8) Universal Protocol – Hospitals are charged with developing guidelines for the implementation of the universal protocol for the prevention of wrong site, wrong procedure and wrong person surgery. There were several sentinel events noted in the self-assessment which appear to demonstrate an absence of a guideline for this crucial standard. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. These events included lung biopsy side unmarked and a knee arthroscopy site not marked.

9) National Patient Safety Goals – The National Patient Safety Goals (NPSGs) have become a critical method by which the Joint Commission promotes and enforces major changes in patient safety in thousands of participating health care organizations around the world. The criteria used for determining the value of these goals, and required revisions to them, are based on the merit of their impact, cost, and effectiveness. Two findings noted in the observation during the PPR included unlabeled basins and pre-labeled syringes.

10) Medical Staff – The organized medical staff and the governing body collaborate in a well-functioning relationship, reflecting clearly recognized roles, responsibilities, and accountabilities, to enhance the quality and safety of care, treatment, and services provided to patients. This collaborative relationship is critical to providing safe, high quality care in the hospital. To meet this standard and to remain in compliance, the Joint Commission (JCAHO) requires accredited hospitals to examine and evaluate performance data for all practitioners with privileges on an ongoing basis as part of their Ongoing Professional Practice Evaluation (OPPE) initiative. It was noted in the interviews with the medical staff the OPPE process does not meet standards.


In preparation for the audit, the self-assessment analysis included a review of current trends that may cause the organization to not be in compliance. Several major trends noted in the case study include Fire Drill History ( Environment of Care) – the data shows that the fire drills were not routinely performed in Nightingale Community Hospital that requires one drill per shift per quarter. There was an average of three drills per quarter with no consistent methodology for conducting the drills per shift or floor. This environment of care standards observation as noted above in the previous section indicated smoke wall penetrations which could have been discovered in there were routine fire drills. Moderate Sedation Monthly Audit (Provision of Care, Treatment and Services) – Moderate sedation provides a minimally reduced level of consciousness in which the patient retains the ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command.

The data showed in the Endoscopy Department a lack of pre-sedation ASA (American Society of Anesthesiology) and no documentation plan of anesthesia noted in endoscopy. The data shows that in pre-procedure, during procedure, and post-procedure no documentation was consistently recorded. The trends show the first quarter had a high of 100% and low of 75% and a fourth quarter high of 100% and low 79%. Pain Assessment Audit (Provision of Care, Treatment and Services) – Pain assessment is diagnostic tool to measure the pain level of a patient before administration of a medication and following administration. The goal is assess the patient’s pain relief and thus the effectiveness of the therapy. The data shows that pain assessment and reassessment is consistently missing in the Emergency Department(ED). The data shows a trend of this occurring with a range of 65% to 82%.

The data shows the other departments listed have a higher a level of compliance. 3E shows a range of 90% to 97%, whereas the Post-anesthesia care unit (PACU) shows a higher range of 95% to 99%. PI (Patient Injury) Data Falls 4E (Life Safety) – Falls in 4E were highly prevalent. The target goal for falls with injury is 0.62 per 1000 patient days. Several months (January, February, April, July, and November) experienced 0 falls. In contrast, the other months experienced rates varying from 1.72 to 5.6. Data suggest trends show a marked increase over the last 7 months as compared to the first five months of the year that the data was collected. The target goal for all falls is set at 3.21. This number was achieved in five months, with 2 months (January and August) experiencing 0 falls. The data for falls overall in 4E appears to conflict with the data shown for fall with injury.

The data shows no falls for the month of August, however, August also reports 4.5 falls with injury. Also, the month of October shows 4.1 total falls vs. 4.37 falls with injury. This brings to mind the reporting of the data, which has to be in error. PI (Patient Injury) Data falls For the Entire Hospital (Life Safety) – Overall, the hospitals falls and falls with injury are lower than that of 4E. That being said, trends show there is a rise in both categories over the course of the year. In total falls there were peak months in March and September showing 5.1 and 4.9 respectively. In falls with injury, three month April thru June showed no injury related falls. Overall, the falls with injury are below the target as a mean total for the year. That being said, data clearly shows a trend towards increase of falls with injury. Prohibited Abbreviations (Information Management) – The Joint Commission has sent forth a list of prohibited abbreviations that should not be used by healthcare organizations.

This list includes but is not limited to medical terminology, disease states, units of measurement, and drug dosage forms. The use of abbreviations can lead to a misinterpretation of meaning which could use lead to an adverse event. The audit monitored the abbreviations “cc” and “qd” because they are the most frequently used prohibited abbreviations. Cubic centimeters are a measurement of volume and are abbreviated”cc”. It is the cubic amount required to hold 1 milliliter of water. If poorly written it can be misread as “U” for units, ml should be used instead of cc. The term qd” means once daily. However, it is often misinterpreted for “qid” which means four times daily or “qod” which means every other day. The word daily should be written out. Aggregate data for the audit included the ICU, Telemetry and floors 3E and 4E. These abbreviations should never be used. The data suggest a high prevalence of the use of these abbreviations.

The abbreviation “cc” was used far more frequently than “qd”. The monthly range for its use was 20 to 47 times monthly according to the data. By contrast the monthly range for the abbreviation “qd” was 10 to 25. The data suggest a steady trend in the use of prohibited abbreviations. Staffing Effectiveness (Nursing Leadership) – Effective staffing by definition is the competency, number, and skill set of staff in its relation to patient care and treatment. The data used by the hospital to measure effectiveness utilizes key indicators from clinical/service screenings and human resource screenings. This data is then analyzed to look at ways to access and improve staff effectiveness on a continuous basis. Clinical indicators include patient falls, patent falls with injuries, ulcer prevalence, and ventilator associated pneumonia (VAP). Human resource indicators include nursing care hours and overtime.

The care areas associated with this data were ICU (intensive care unit), 3E and 4E. The data suggests no trends in relationship to nursing hours and falls and nosocomial ulcers in 3E. In ICU, data shows a decrease in falls from previous year from 4.1 to 1.9 per 1000 patients. Of the 1.9, which represents seven falls, five occurred in the first quarter of FY09. VAP increased from 2.2 per 1000 ventilator days to 3.0 for current year. Trends show a decrease in falls however an increase in VAP. Trends also show a decrease in nursing care hours. In 4E, there was an increase in patient falls and nosocomial pressure ulcers.

Falls increased to 4.37 per 1000 patient days as compared to 1.47 per 1000 the previous year. Trends shows there appears to be relationship with falls and nursing care hours which shows an increase. There was also a slight increase in nosocomial ulcers during the period which appears to be a relational trend. Verbal Orders Authenticated Within 48 Hours (Record of Care) – Data indicates a trend showing a decrease in verbal order authentication during the year collected. Quarterly averages show: Q1-84%, Q2-87%, Q3-73%, and Q4-81%. The first half year average is 85.5% as compared to second half year average of 77%.



In analyzing the data, 3E (Oncology) maintained a relative consistent range of hours in nursing care over the course of the year. Peak nursing hours were used in the month of October which corresponded with the lowest amount of fall prevalence. However, the second month with the highest amount of nursing care hours had the highest amount of fall prevalence. There is also a linear trend showing an increase in falls over the course of the year. Data shows a decrease in nosocomial ulcers over the same time period. Prevention of falls and nosocomial ulcers are a focus point of this unit due to patient population. Several staff members attended the NICHE program. The name stands for Nurses Improving Care for Health system Elders and is designed to improve recognition of age-related changes and increase nurses’ sensitivity. Nursing staff members who attended program shared knowledge with their colleagues and changes were implemented to improve patient care and outcomes.

Changes included nurses prompting patients every two hours to void while awake to decrease urgency which could lead to falling or incontinence which could lead to pressure ulcers. The unit’s nosocomial ulcers decreased from 2.76% in FY08 to 1.23% in FY09. The units’ year end falls average was 5.45 compared to previous years 5.57. The linear trend which shows an increase in falls over the course of the most current year indicates that more training is needed. 4E experienced an increase in nosocomial ulcers and falls during the past year. The relational trend in nursing hours shows an increase through the year. The trend towards ulcers also shows an increase in through the year.

However, the peak month for nosocomial ulcers shows occurred during the month that the third fewest nursing hours were used. This does not indicate a relational trend. The number of falls in 4E increased sharply in the year compared with the previous year. The current year showed an increase average to 4.37 as compared to the previous year’s average of 1.47. The peak month occurred in December showing an ever increasing trend. The nursing hours increased over the course of year. Data appears to suggest a relational trend with nursing care hours and patient falls. ICU showed an increase in falls from 1.9 from the previous year’s average of 0.41.

Five of the seven falls that occurred happened in the first quarter of FY09. There appears to be no correlation between nursing care hours and patient falls. VAP (ventilator associated pneumonia) increased from 2.2 per 1000 ventilator days to 3.0. This number indicates two infections versus one infection during the respective fiscal years. There appears to be no relational correlation with VAP and nursing hours. Due to the increase in VAP, the following actions were implemented that included:

* VAP bundle implementation including sedation vacation
* Mouth care protocol
* Daily rounds with the intensivist


Based on the data, an initial conclusion can be drawn the number of falls decreased in 3E based on nursing staff after attending the NICHE Program and sharing information learned with colleagues the increase of falls prevalence through the year suggests more training is necessary. The other units could also benefit from more training conducted on a monthly basis with the desired outcome to reinforce policy and to impact future accreditation reviews. Inpatient working conditions have deteriorated in some facilities because hospitals have not kept up with the rising demand for nurses. This situation has motivated some state legislatures to enact or consider regulatory measures to assure adequate staffing. These regulatory measures assign some minimum level of staffing that all hospitals must meet regardless of the types and severity of patients. The number of nurses is not always a mitigating factor in the reduction of patient falls.

However, there are a number of variables which should be factored in reviewing the falls such as fatigue from mandatory overtime with patient care and time consuming but necessary administrative tasks such updating patient records and documenting physician and other medical orders etc. Model Staffing Patterns — In researching, various staffing models several require acute care hospitals maintain minimum nurse-to-patient staffing ratios. Required ratios vary by unit, ranging from 1:1 in operating rooms to 1:6 on psychiatric units. Most state legislation also requires that hospitals maintain a patient acuity classification system to guide additional staffing when necessary, assign certain nursing functions only to licensed registered nurses, determine the competency of and provide appropriate orientation to nurses before assigning them to patient care, and keep records of staffing levels.

The Joint Commission recommends all nursing units be supervised by a registered nurse. Nursing Staffing Plan Based on Type of Care — Another factor for consideration is the knowledge, skills and ability of the individual nurse. The safety and quality of patient care is directly related to the size and experience of the nursing workforce, Such as thoroughness in documentation, following protocol, and work pace. A comprehensive staffing pattern will have to take this into account in terms of reviewing the effectiveness of the individual nurses to reduce the occurrence of incidents. The chief nurse must monitor the performance of the nursing staff on a continuing and ongoing basis.

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