Editor's note: Each installment of Joint Commission Standards will review a chapter of the Comprehensive Accreditation Manual for Hospitals and may be distributed to staff as a teaching tool needed for Meeting the Challenge of Constant Readiness.

The chapter on Improving Organizational Performance (PI) is short in volume, but large in impact. Performance improvement is an ongoing process focusing on outcomes of care, treatment and services. It seeks to incorporate risk-reduction factors into all systems to effectively reduce the potential for medical error and adverse outcomes. The chapter is divided into three essential components of performance improvement:

· measuring performance through data collection;
· assessing current performance; and
· improving performance.

 Avoiding Common Pitfalls

PI.1.10 The hospital collects data to monitor its performance.

Hospital leadership decides on the type of hospital-wide data to be collected. The collected data often determine the priorities for performance improvement. Through the years, the criteria for monitoring have been areas of high volume, low volume/high risk and high cost, as well as those prone to problems. Elements of Performance (EP) 3 requires hospitals to collect data on the following high-risk processes:

• medication management;
• blood and blood product use;
• restraint and seclusion use;
• behavioral management;
• operative and other invasive procedures; and
• resuscitation and its outcomes.

In addition, EP 3 requires relevant information from the following areas be integrated into the PI process:

·  risk and utilization management;
·  quality control;
·  infection surveillance;
·  research;
·  autopsies performed; and
·  organ procurement.

 PI.2.10 Data are systematically aggregated and analyzed.

The five EPs associated with this requirement basically state data collected is of no value unless it is aggregated, analyzed and compared to internal and external benchmarks. Aggregate data identify trends. Benchmarking identifies the norm or acceptable levels of care. Analysis through the use of statistical tools and techniques determines whether trends are significant enough to require action.

When goals or benchmarks are not achieved, exploring potential causes and solutions begins. Aggregate data with benchmarks should be shared with the staff of care areas or departments impacted by it. Filtering information down to individuals who provide the care or perform the tasks often has been a stumbling block to change. Engaging staff in performance improvement initiatives and familiarizing them with current methodologies, whether you use a simple Plan, Do, Study, Act concept or the complex Six Sigma, creates a climate for change.

PI.2.20 Undesirable patterns or trends in performance are analyzed.

The Joint Commission clearly states performance improvement topics are chosen by hospital leaders, but it also mandates analysis occurs in the following instances:

·  confirmed transfusion reactions;
·  all serious drug events and significant medication errors;
·  major preoperative and postoperative discrepancies;
·  adverse events or patterns related to moderate sedation and anesthesia use;
· hazardous conditions;
· staffing effectiveness issues; and
· core measure data over a period of time identify the hospital as a negative outlier, or one that is not meeting goal over 3 or more consecutive quarters for the same measure.

Staff education related to these occurrences focuses on the action in place to improve performance or prevent reoccurrence. For instance, if a significant medication error occurs involving insulin, it is not expected that staff describe the event, but recognize insulin has been identified as a medication of high risk and identify the steps to prevent medical error in the use of insulin.

PI.2.30 Process for identifying and managing sentinel events are defined and implemented.

· Staff can define a sentinel event and how they would communicate the occurrence of such an event.
· The EPs go on to require reporting of sentinel events to external agencies based on law, completing a credible root-cause analysis, and initiating risk-reduction strategies and action plans to prevent reoccurrence.

PI.3.10 Information from data analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events.

The EPs for this standard emphasize that change to improve care and safety is based on data analysis. When change is made, it is evaluated for effectiveness. If the change is not effective or sustained, action is taken.

PI.3.20 An ongoing proactive program for identifying and reducing unanticipated adverse events and safety risks to patients is defined and implemented.

· The focus here is preventing adverse events rather that reacting to them.         
· Hospitals are required to complete at least one risk assessment on a high-risk process a year. The method used for the risk assessment often is referred to as failure mode effect analysis (FMEA).

Involving individuals who perform the process steps is important to the success. The FMEA results are shared with the staff of care areas or departments impacted.

Jean Kalemba was previously director of performance improvement at Mountainside Hospital, Montclair, NJ. She is skilled in developing and implementing programs to meet hospital regulatory agency requirements and has an excellent record in preparing organizations for licensing and accreditation surveys.