Have you addressed the new Joint Commission Performance Improvement standards that went into effect January 1st? They’re in both the Hospital manual and the Behavioral Health Care & Human Services manual. If not, now’s the time to do so.

These new PI requirements have been in place for several months. As a result, surveyors are now focusing on this topic. They’re asking more probing questions about PI tools and the how PI teams use data.

2022 Joint Commission Performance Improvement Standards: What’s Different?

The new Joint Commission PI standards require a more structured approach to PI than in the past. In addition, they require leadership to clearly identify in the PI Plan the particular processes that need improvement.

Specifically, the new standards require you to do the following:

• Develop a written PI Plan
• Identify the processes that need improvement
• Define the methods you’ll use to:
  • Measure performance of these processes
  • Identify poor performance in these processes
  • Improve performance of these processes
  • Monitor and sustain the improvements you make

There are a couple of critical take-away’s here. First, your PI Plan should not just describe your PI structure (governing body, committees, etc.) as it has, perhaps, done in the past.

It should also specifically identify the processes you’ve determined need improvement. That means you’ve analyzed your data and concluded these particular processes need to be improved.

Second, your PI Plan should identify the specific PI approach and tools your organization will use. TJC specifies that your PI approach should be an evidence based methodology.   For example: Lean, Six Sigma, or Change Management.

Why is TJC advocating evidence based PI methodologies?  Essentially, they’ve determined organizations with highly successful PI programs have adopted an established PI methodology and use the PI tools associated with that methodology.

Survey Readiness

Given the new focus of the Joint Commission Performance Improvement standards, what should you do to be survey-ready?

First, carefully review TJC’s R3 Report # 31: New and Revised Performance Improvement Accreditation Standards.

Next, make sure you’ve updated your PI Plan to include all the components required by the new standards and discussed herein.

Last, prepare documents to demonstrate you’ve met the new PI requirements. These should include:

• Your updated PI Plan including the processes you’ve identified for improvement
• Evidence your Leadership Team and Governing Body were involved in identifying these PI priorities
• Documentation of your formal, systematic approach to PI

Feedback from the Field

The PI Director of a large behavioral health organization recently shared feedback on how they addressed the new Joint Commission Performance Improvement standards:

“We used the new PI standards as an opportunity to overhaul our existing PI program. We had gotten bogged down in a bunch of committees looking at the same data every month but not doing much with it.

So, with the new TJC focus on measurable process improvement, we had our leadership team identify what they saw as the top priorities for PI for the coming year. They chose two things: retention of mental health workers and reduction in the use of holds.

We formed two PI teams and trained them in the FOCUS-PDCA model and tools. Next, we gave each team a clear charge, specific deliverables, and timelines.

As a result, we’re already starting to see measurable gains with this approach. In addition, team members report  it’s a much more dynamic, results-oriented approach than in the past and they feel more engaged.”

Barrins & Associates Resources

Like TJC, we’re back to business as usual. We’re busy conducting Mock Surveys and Continuous Readiness Consultations. We’ve incorporated these new PI standards into the Data Use Systems Tracer we conduct on all mock surveys.

As always, we’re prepared to support your ongoing survey readiness and best practices for regulatory compliance.