JCAHO PI standards revised
Access http://www.jcaho.org/pubedmul/ publicat/pistan.htm on the Internet to see the Joint Commission's proposed revisions to its Comprehensive Accreditation Manual for Hospitals. What you'll find when you get there is a list of revised standards, the intent of the revisions, and scoring for the standards. For example:
Standard PI.3 Data are collected to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement, and maintain changes.
Intent for PI.3 Collected data help the organization evaluate outcomes or determine the performance of a function or process. When data collection is systematic, it can be used to
· establish a performance baseline
· describe process performance or stability
· describe the dimensions of performance relevant to functions, processes and outcomes
· identify areas for more focused data collection
· sustain improvement.
The judgments made about stability or performance are used by the leaders to identify and prioritize issues for more focused data collection (refer to LD.0.00 for leaders using criteria to prioritize data collection for improvement).
Scoring for PI.3 This standard is scored at PI.3.1 through PI.3.3
The proposed revisions are part of the Joint Commission's periodic review to keep the chapter on PI standards current. They're intended to increase the emphasis on performance measurement, minimize sentinel events, and stress the need for sustained improvement. Key revisions involve:
· An expansion of the intent statement for standard PI.4.3 focuses on the prevention or elimination of sentinel events and introduces root-cause analysis as the key element of the intensive analysis process. (See Patrice Spath's article on root-cause analysis, below.) The standards that address specific events would be collapsed into this intent statement.
· A revision of the intent statement for standard PI.5 makes it clear that once performance is improved, the expectation is that the improvement will be sustained.
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