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Get Ready! Effective January 1, 2022, new TJC Performance Improvement Requirements go into effect. They’ll be in both the Hospital Standards PI chapter and the Behavioral Health Standards PI chapter.

What’s Changed?

The new TJC Performance Improvement Requirements essentially “raise the bar” on what TJC expects to see in your Performance Improvement program. So, let’s take a look at the details.

Role of Leadership in Setting PI Priorities

First, it’s important to note the new PI standards require that “leaders (including the governing body) set priorities for performance improvement activities and patient health outcomes.” Thus, it’s the role of leadership to identify the top organization-wide priorities for the PI program.

Realistically, in any organization, there may be many processes that need improvement. However, the role of leadership is to identify the most critical ones on which to focus PI efforts.

Too often, we find organizations have a myriad of PI projects. These projects, although well intended, often have no clear timelines and deliverables. As a result, they become diffuse and lose impact.

New TJC Performance Improvement Requirements: Written PI Plan

TJC will now require a written PI Plan. Interestingly, this was a requirement several years back. Now, TJC is requiring it once again.

We do notice that many organizations retained their written PI plan. Others did not. Particularly, since it’s not currently on the Documents List in the TJC Survey Activity Guide. We assume TJC will add it to the 2022 Documents List.

Next, you must review and update the PI plan annually. Your updates should be based on changing priorities due to factors in the internal and external environment. For example, the COVID-19 pandemic would clearly have been such apriority.

New TJC Performance Improvement Requirements: Definition of your PI Process

The new standards also require a more robust definition of your PI process. Specifically, your PI Plan must describe the following:

  • The defined processes needing improvement including any stakeholder requirements, project goals, and improvement activities
  • Methods for measuring performance of the processes identified for improvement
  • Analysis methods for identifying causes of variation and poor performance in the processes
  • Methods implemented to address process deficiencies and improve performance
  • Methods for monitoring and sustaining the improved processes

Survey Readiness: What to Do Now

First, carefully review these new requirements with your leadership team. Likewise, check out TJC’s R3 Report # 31: New and Revised Performance Improvement Accreditation Standards.

Next, convene a team comprised of senior leaders and Quality Management staff to make recommendations about any changes needed to your PI program. Then, review these recommendations with your governing body.

Last, prepare the documentation that will show surveyors you’ve met the new requirements. Specifically:

  • You have an updated PI Plan.
  • You’ve identified clear priorities for what your PI projects will be.
  • You have a formal, systematic approach to measuring your improvements.

Barrins & Associates Resources

TJC is now back to “business as usual” for the most part. Likewise, 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.