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Conquering performance improvement documentation for JCAHO.

When the Joint Commission on Accreditation of Healthcare Organizations published its 1996 Comprehensive Accreditation Manual for Hospitals,(1) our facility redesigned its performance improvement (PI) program to coincide with JCAHO's terminology for improving organizational performance. Our laboratory had long been involved in quality assessment and performance improvement programs and was following the College of American Pathologists guidelines. Still, we elected to revise our PI program to dovetail with that of the hospitals.

JCAHO's improving organizational performance (IOP) standards P1.1-5 (plan, design, measure, assess, and improve), otherwise known as PDMAI parameters, outline a specific cycle for improving performance (see Table 1).

While JCAHO's five parameters appeared to be straightforward, we soon discovered that developing a structured, easy-to-follow format that would enable us to document them was no easy task.

Prioritizing efforts

Fortunately, our hospital had already adopted a prioritization grid to evaluate and prioritize proposed PI opportunities, so we were off to a good start. The following nine aspects of a proposed PI project are subjectively ranked on a scale of 0 to 5, where 0 indicates the factor has "no effect" and 5 indicates the factor is "potentially life-threatening" (see Table 2).

1. High risk: If the process fails, then there is a high health risk to the patient.

2. High volume: The process or procedure is performed frequently on a regular basis.

3. Problem prone: The process or procedure is subject to failure due to complex steps.

4. Important to mission: The process directly supports the laboratory's or healthcare facility's mission statement.

5. Patient expected/needed: The process directly affects or supports a patient's expectation or need.

6. Staff expected/needed: The process directly supports a staff member's expectation or need in accomplishing a process or a step in a process.

7. Clinical outcome: The process influences the ability to effectuate a positive patient outcome.

8. Safety: If the process is not performed correctly or if it fails, it could result in physical harm to the patient or employee.

9. Regulatory requirement: The process is required by a governing or regulatory agency.

Before we could begin using the grid, however, we needed to determine which proposed P! opportunities did not warrant our time. By evaluating successful PI projects from the previous year (also using the grid), we determined that proposed projects with a total score less than 15 would not be a priority.

PI format

With a set method in place to evaluate where to focus our improvement efforts, we now needed a standardized format to help us document our activities (which we intended to make consistent with JCAHO's PDMAI cycle) and to ensure that our projects would be easier to review (see Table 3). The following is a description of the particular PI format we developed:

Plan. Section 1 of our PI format highlights a particular patient care problem. For example, "Aspect of care," delineates the specific aspect of patient care involved in our PI monitor. We also include statements that support why the process being examined is important to a particular customer, be it patients, physicians, or nurses. Relevant regulatory standards required by inspection agencies are included here as well.

A performance improvement prioritization grid immediately follows "Aspect of care." See Table 2 for an example of the top portion of the grid.
Table 1

JCAHO's standards for organizational performance improvement (PI)

Plan (PI 1): The organization has a planned, a systematic,
 organization-wide approach to designing,
 measuring, assessing, and improving its

Design (PI 2): New processes are designed well.

Measure (PI 3): The organization has a systematic process in
 place to collect data.

Assess (PI 4): The organization has a systematic process to
 assess collected data.

Improve (PI 5): The hospital systematically improves its

Design. Before completing the "Customer requirements" subsection, laboratorians must have a clear understanding of who the customer is, as well as what the client's specific requirements are for the product, service, or process being examined.

The "Current process" subsection describes the process being used. Whenever applicable, we include a process flow diagram to simplify the presentation and review of the process.

"Methods" outlines the procedures that will be used to conduct the PI monitor. Specifically, the "Methods" subsection should answer these questions:

* What data will be collected?

* How will the data be collected, tabulated, and documented?

* Where will the data be collected?

* What additional training, if any, will be needed to conduct this study?

* Who will summarize and present the data?

Copies of any of the forms used to record collected data should be included in this subsection, too.

Measure. This section consists of four subsections: "Indicators to be used," 'Threshold of acceptable performance," "Measurement tools to be used," and "Results." Care must be taken to develop well-defined indicators for "Indicators to be used." Laboratorians must be sure they are collecting the fight data from the appropriate steps in the process and are focusing their attention on the correct population. If, for instance, a lab wishes to monitor the turnaround time for Star electrolytes in the emergency department during the day shift, indicators should include all ER patients with Stat electrolytes requested between the hours of 7:00 am and 4:00 pm.


As the title indicates, "Threshold of acceptable performance" is where the minimum level of acceptable outcome or performance is documented. This threshold can be developed from customer requirements, historical data, professional literature, or benchmarking. The threshold set will be the measuring stick against which a lab ultimately will determine if its goals have been met.

The "Measurement tools to be used" subsection outlines what instruments laboratory employees will use to measure progress. These might be data collection forms, statistical programs (e.g., linear regression analysis, standard deviation, coefficient of variation), special instrumentation, or required data calculation tools.

The "Results" subsection is where data are actually presented using charts, graphs, tables, and/or process flowcharts (depending on the type of information collected). The PI documentation format outlined in this article allows our lab staff to complete all sections up to this one before actual data are collected enabling us to review all proposed PI projects to ensure that all parameters have been covered and that we are conducting a focused study rather than wasting time and resources on an inappropriate or poorly designed project.

Assess. In this section, results are compared to those found in the "Threshold of acceptable performance" subsection to determine if the PI project's goals have been met. The "Interpretation of results" subsection enables us to evaluate our results and to determine if we are over or under our established threshold. If we discover we are not within our boundaries, we look for common causes of deviation and evaluate the process for improvement opportunities. In "Improvement opportunities," we determine whether any areas can be improved, and if so, how. Here we include cause-and-effect diagram, s and Pareto charts, if possible. Conclusions derived from our data are incorporated in this section as well.

Improve. This final section contains two subsections: "Action" and "Track effectiveness." The first subsection enables us to document how we have improved a particular process. As part of this action plan, we communicate our findings to all those who were involved in the PI project. Lastly, to ensure that our improved process will continue to perform as expected, the "Track effectiveness" subsection contains data supportive to the fact that our process change continues to be effective.

Finally, before presenting our findings to the hospital's CQI committee and to inspection agencies, we add two columns to the grid: "Results" and "Action/Improvement plan." These two sections contain a capsulated version of our PI efforts.

There is no guarantee that a facility using our particular format alone for its PI plans will satisfy agency inspectors. Nevertheless, our standardized plan should help any organization organize, review, and present its PI efforts as well as meet all documentation requirements. It certainly has been a tremendous help to us!

Table 3

Blood bank performance improvement: Autologous blood transfusion practices, 1997

1. Plan

A. As of care B. Performance improvement prioritization grid

2. Design

A. Customer requirements B. Current process (use a process flow diagram, if possible) C. Methods

3. Measure

A. Indicators to be used B. Threshold of acceptable performance C. Measurement tools robe used D. Results

4. Assess

A. Interpretation of results B. Improvement opportunities

5. Improve

A. Action B. Track effectiveness


1. Joint Commission on Accreditation of Healthcare Organizations. 1996 Comprehensive Accreditation Manual for Hospitals. JCAHO; Oakbrook Terrace, Ill: 1995.

Rustin L. Holmes is information systems manager at Bangor Area High School in Bangor, PA, and president of Management Dimensions, a private management consulting firm in Bangor. At the time of writing, Rustin was assistant laboratory manager at St. Peter's Medical Center in New Brunswick, N.J.
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Title Annotation:Joint Commission on Accreditation of Healthcare Organizations
Author:Holmes, Rustin L.
Publication:Medical Laboratory Observer
Article Type:Cover Story
Date:Jun 1, 1998
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