Performance review survey

  • Accreditation is a way of evaluating quality and safety in your organization. It is an audit of the actual delivery of critical services and patient care.
  • Accreditation is a continuous process, providing insight into your organization’s daily operations and systems.
  • The unannounced survey is a validation of your organization’s continuous improvement efforts.
  • A final accreditation decision will be made after Joint Commission staff review and approve the health care organization’s Evidence of Standards Compliance (ESC) and any identified Measures of Success (MOS), which are four-month audits of the success of the corrective actions, as appropriate. The Central Office review is completed within 30 days of receiving the ESC. If the health care organization successfully addresses all of its requirements for improvement, the organization will be accredited. The final accreditation decision will first be posted on the Joint Commission’s secure Extranet site, Joint Commission Connect, which your organization can access. The final decision will then be posted on Quality Check, a Joint Commission Web site where users can search for information about any accredited organizations.

With this process come new measures of achievement for your organization:

  • Focus on successfully achieving accreditation, which is recognized nationally as the Gold Seal of Approval™ in health care.
  • Focus on the fact that your organization has undergone an unannounced, thorough on-site review of the quality and safety of care being provided and is committed to continuously meeting rigorous national standards. The conclusion of the on-site survey is a validation of the work to continuously comply with The Joint Commission’s nationally developed standards.
  • Emphasize your organization’s public commitment to continuous improvement and delivering safe, high quality care.
  • Stress how ongoing compliance with Joint Commission standards results in sound management practices in the day-to-day delivery of safe, high quality care and give examples. In fact, the Joint Commission survey serves as an independent audit of your organization’s commitment to continuous quality improvement.
  • Share information specific to your organization about what accreditation means by detailing your organization’s full compliance with particular areas of the accreditation process, such as challenging standards, or your organization’s level of compliance with the standards.
  • Emphasize your organization’s compliance with the National Patient Safety Goals.
  • Demonstrate your organization’s successful performance by sharing your ORYX® data or National Quality Improvement Goals (for hospitals only). As more measures are approved and endorsed by the National Quality Forum (NQF), the Joint Commission will explore ways to incorporate that data into Quality Reports.
  • Stress your organization’s focus on continuous standards compliance and point out the organization’s commitment to maintaining care processes for patients, residents, or clients that are safe and that meet high quality standards.
  • Compare systems issues identified during the Periodic Performance Review process with the on-site survey findings, and emphasize the improvements made as a result of this ongoing work.
  • If there are ESC and MOS requirements, your organization may want to share information about these improvement efforts. For example, leadership might compare this process to a financial audit by an accounting firm in which organizations have an opportunity to either present evidence contrary to the auditors’ findings, or accept the report and implement improvement strategies.
  • Discuss how staff involvement in the accreditation process was vital to the success of the on-site survey because the tracer methodology focuses on the direct care of the patient, resident or client.

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