Patient Care Facility Accreditation Guide

The Performance Management Standards allow organizations to track and trend strengths and weaknesses in business and patient-care operations. Patient-care businesses must have a program to monitor, evaluate, and improve quality.

Effective programs require organizational support, data collection, and data analysis.

PM.1

You must have a written performance management program that does the following:

1. Monitors and evaluates the quality and appropriateness of patient care

2. Seeks opportunities to improve services

3. Resolves identified problems

The governing body of your business must support the performance management program by documenting, requiring ,and participating in the program.

Tip

Your performance management program must define these elements and include the appropriate response times for corrective action. The effectiveness of the action you take must be assessed, reported, and communicated through the proper channels in your business.

PM.1.1

You must document how you seek input from employees, patients and referral sources when assessing the quality of your operations and services. This should be an ongoing activity but must be done at least annually.

Tip

You may do this through staff meetings, staff interviews, patient surveys or interviews, meetings with your referral sources, or other means. Any method you use to seek input must be documented in a file for this purpose.

PM.2

Your performance management program must include the use of a patient satisfaction survey.

Tip

If you do not have your own patient satisfaction survey, one is available in the Resource Kit on the ABC website. It is recommended that your patient satisfaction survey be conducted within two months after providing a new or replacement device. Your survey should be designed to gather many types of information, which are detailed in Standards PM.3, PM.4, and PM.5 and included in the Resource Kit sample.

PM.3

You must collect, monitor, and measure patient satisfaction with the items and services provided.

Tip

You must solicit feedback from your patients on their satisfaction with the items and services you provide. Once you have collected this data, you need to measure the results to identify areas that may need improvement.

PM.4

You must collect, monitor, and measure the timeliness of response to patient questions, problems, and concerns. For any formal complaints, you must notify the beneficiary within 5 calendar days that the complaint has been received and is being investigated. You must provide the patient or caregiver with written notification within 14 calendar days of the results of the investigation of their complaint. Documentation of all complaints and the results of their investigations must be maintained.

Tip

This could be documented in your patient complaint log and/or patient satisfaction survey.

PM.5

You must collect, monitor, and measure the impact of your business operations on the adequacy of patient access to equipment, items, services, and information.

Tip

This measurement of your business practices can be accomplished through patient surveys.

PM.6

You must collect and measure data to evaluate the frequency of billing and coding errors.

Tip

You must have a policy that measures the frequency of billing and coding errors. You could use documents such as patient records, billing logs, and/or rejected claims reports to collect this data. Use the Billing and Coding Error Report in the online Resource Kit to record your findings.

PM.7

You must collect and measure data to monitor any adverse events to patients due to inadequate or malfunctioning equipment, items or services once you become aware of such adverse events.

Tip

Once you are aware of deficient or broken equipment, you must provide documentation (patient records, patient incident reporting policy and procedures) that you are identifying and monitoring the impact to your patients. Examples of adverse events are injuries, accidents, signs and symptoms of infection or hospitalizations.

PM.8

You must collect and evaluate data that allows you to identify and monitor adverse or beneficial trends associated with the quality of care for your patients.

Tip

Your performance management plan must include measures of the outcomes of consumer services, billing practices and adverse events. Information can be gathered through follow-ups, patient record reviews, outcome studies, and/ or patient satisfaction surveys.