Joint Commission acronyms and terms driving you crazy? Here are a few definitions for some of the more common ones:
Glossary of Common Joint Commission Acronyms and Terms | ||||
Accreditation (Joint Commission)
Statement of approval by the Joint Commission that indicates an organization complies with applicable Joint Commission standards. Also confers deemed CMS approval.
CSG - Clinical Service Group
Patients or services categorized into distinct populations for which data can be collected. (See pages 44-45 of the 2007 HAS for the list of hospital CSGs.
EP - Element of Performance
Compliance with the standards is scored by determining compliance with Elements of Performance, which are specific performance expectations that must be in place for an organization to provide safe, high quality care, treatment and services. EPs are scored on a three-point scale: 0 = insufficient compliance, 1 = partial compliance, 2 = satisfactory compliance
EP - Category A
Relates to presence or absence of a requirement, generally scored either yes or no.EP - Category B
Scored in two steps. Step one relates to presence or absence of a requirement, generally scored either yes or no. Step two evaluates concerns about quality or comprehensiveness of the effort.EP - Category C
Scored 0 = insufficient compliance, 1 = partial compliance, 2 = satisfactory compliance based on the number of times the hospital does not meet the EP.
HAS - Hospital Accreditation Standards
Standards specific to hospital accreditation.
MOS - Measure of Success
A quantifiable measure used to determine whether an action is effective and sustained. Developed for particular standards judged to be out of compliance through the onsite survey. Applicable EPs are identified by the MOS icon.
PFA - Priority Focus Areas
Issues that are most relevant to safety and quality of care.
PFP - Priority Focus Process
Compilation of available data from a variety of sources including e-Apps, previous survey findings, complaint data, and publicly available external data. Focuses survey activities on the organization-specific issues that are most relevant to safety and quality of care.
Plan of Action
Detailed description of how a standard identified as not compliant in the PPR will be brought into compliance.
PPR - Periodic Performance Review
A compliance assessment tool designed to help organizations with their continuous monitoring and performance improvement activities. Enables self-evaluation of compliance with all Accreditation Participation Requirements, National Patient Safety Goals, applicable standards and Elements of Performance (EPs), and develops a Plan of Action for all areas of performance identified as needing improvement.
The completion of the PPR is an Accreditation Participation Requirement for hospitals, laboratories and organizations providing ambulatory care, behavioral health care, home care and long term care. Updated and submitted to Joint Commission annually.
Primary Source
Original source, or an approved agent, for a specific credential.
Professional Practice Evaluation
Evaluation of individual provider's practice patterns for the purpose of maintaining clinical privileges. May include chart review, observation, monitoring, and discussion with others involved in patient care.
Rationale
Background, justification, or additional information provided about a standard. Not scored.
Standards
Statements that define performance expectations and/or required structures or processes.
Tracer
Analysis of an organizaton's systems, with particular attention to identified priority focus areas, by folowing individual patients through the health care process.
Do you have an approved abbreviation list?
Posted by: Virginia C Woodrow, MD | June 17, 2009 at 03:35 PM