Additions and Revisions to Performance Improvement and Leadership Standards

Updated: May 19




A Closer Look at Joint Commission Nursing Care Center Standards:


PI.02.01.01- The organization has a written plan that describes quality measurement and performance improvement activities.

PI.04.01.01- The organization improves performance.


Performance improvement plans help organizations identify areas or processes of inadequate performance and aid in establishing a path to ensure improvement. Performance improvement plans can be implemented for many different reasons ranging from reducing falls to improving hand hygiene compliance, all of which help create a safe environment for residents and staff.


Effective January 1, 2022, The Joint Commission will be revising and adding to the Performance Improvement and Leadership standards. Revisions will include the need for organizations to incorporate use of an established improvement methodology and its associated tools, and for organizations to develop and maintain relevant and manageable quality improvement plans. To meet these revised and added standards, organizations will need to ensure their written performance improvement plans outline the process(es) that needs improvement, the stakeholders involved, and what performance improvement activities will be involved. The methods for measuring improvement, an analysis of failures and poor performance of the process(es), methods implemented to address deficiencies and methods for sustaining and improving the process(es) will also need to be included in the written performance improvement plan.


Annually, leadership at the organization needs to review the plan for addressing performance improvement priorities. Updates and changes should be addressed at this time. It is extremely important that leadership review performance improvement priorities annually to ensure the proper areas or processes requiring improvement are addressed.

Organizations can choose which methodology they will utilize depending on the performance improvement plan. An example of an accepted performance improvement methodology would be Lean Six Sigma.


Reference: New and Revised Performance Improvement Accreditation Standards



Kerri Hackstock, MA is Vice President of Achieve Accreditation. Achieve Accreditation has helped skilled nursing providers and assisted living organizations to obtain and maintain their Joint Commission Accreditation for over 30 years.