Patient Care Facility Accreditation Guide

October 2023


Performance Managementand Improvement (PM)

The Performance Management Standards allow an organization to track and trend the strengths and weaknesses of your business and patient care operations. Business’ providing patient care must have a program in place to monitor, evaluate and improve the quality of patient care. Effective performance management programs require the following:

1. Organizational Support -- Organizational management must dedicate adequate resources to create and administer a Performance Management and Improvement program. Clinical, administrative and managerial staff should be motivated and competent to fulfill their responsibilities.

2. Data Collection -- You must identify and measure the factors that affect the quality of patient care. While Standards PM.2–PM.7 specify key indicators to measure, you may determine additional areas to monitor. Determining performance guidelines and goals will help you decide what data elements are most important and relevant to your patients and your business. Questions to consider: How will you know when you are performing well? How will you know if you need to make changes? The answers can help you decide what information to track. A Patient Satisfaction Survey is a powerful tool for performance feedback.

3. Data Analysis -- After collecting information, the next step involves making sense of the raw data. Since you used guidelines and goals to decide what to monitor in your data collection, you should use those same guidelines and goals to compare where you are now to where you want to be in the future. When you look at data collected over a period of time—monthly, quarterly or annually, depending on your facility’s size—you are better able to analyze trends and identify organizational changes that need to be made. A performance management system will help you focus on longterm vision instead of a short-term crisis.


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.


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


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 on-going activity but must be done at least annually.


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.


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


If you do not have a patient satisfaction survey of your own, 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.


The results of the patient satisfaction survey must be documented and evaluated, at least annually.


You must use the results of the patient satisfaction surveys to improve your business performance and the quality of care and services that you provide. Your performance management program must document that you use surveys and include how you evaluate and incorporate the survey results.


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


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 in order to identify those areas that may need improvement.


You must collect, monitor and measure the timeliness of response to patient questions, problems and concerns. For any formal complaints, you must provide the patient or caregiver with written notification within 14 days of the results of the investigation of their complaint.


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


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


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


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


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.


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.


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.


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.


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


Action must be taken when you identify an opportunity to improve the quality of care. The effectiveness of the action taken must be evaluated through continued monitoring. Your recommendations, actions and conclusions must be documented.


Potential improvements could be identified through patient satisfaction survey assessments, staff meetings, interviews with patients, referral sources or other means. You must document both the action taken and the monitoring of its effectiveness. 


                                                                                                                                                                                      You must perform a written review of your performance management program at least                  annually. You must document any changes to your performance management processes.



Document your review with notes, a report or meeting minutes. If your review identifies needed changes, you must also update the appropriate performance management program manuals or files.