For one Washington hospital, making the move from Joint Commission accreditation to DNV Healthcare, Inc.'s NIAHO accreditation was a matter of research, timing . . . and moving at a lightning pace.
Group Health Central Hospital is part of Group Health Cooperative, an integrated delivery and financing system providing care to approximately 400,000 residents of Washington and Northern Idaho. The organization operates 26 primary care centers, three specialty centers, and one hospital.
"It all started out at the annual Institute for Healthcare Improvement National Forum," says Elizabeth Rosen, RN, BSN, director of quality and regulatory compliance for Central Hospital. "DNV was there, and I discussed the situation with them, and came back to share my interest with our leadership."
The hospital's chief of hospital medical staff, director of clinical operations, and Rosen met with DNV first to determine whether the change was worth pursuing. Next, they brought in hospital administration, the chief nursing officer, the vice president of acute care, and legal counsel.
"I had outlined a proposal with a comparison of The Joint Commission and NIAHO standards," says Rosen. "People were all positive, though there was some concern about the timeframe."
And what a timeframe it was—the hospital was due for a Joint Commission survey any time after January 1. Regardless of whether it was changing accrediting organizations, Group Health was subject to the survey, and could not change accrediting organizations if it had any outstanding requirements for improvement with the old accrediting organization.
The decision went from hospital leadership to the CEO of the overall organization.
"The CEO, in consultation with the board of trustees, made the final decision," says Rosen. "At the same time, this decision-making process was going on, we did a high level gap analysis to look at the differences between DNV and the Joint Commission, to understand where our focus areas would be."
The hospital's legal counsel reviewed the contract template, and the application was filled out during the decision-making process because everyone involved knew the change would have to happen fast.
"We made the final decision to withdraw from The Joint Commission, and immediately following withdrawal sent our application to DNV," says Rosen.
After signing the contract, the hospital began working with DNV to establish a timeline for the survey process—all in all, there was about a month between the signing of the contract and the arrival of DNV surveyors.
"We had to move very quickly," says Mary Lou Calise, RN, BS, MSQA, CPHQ, quality consultant for Group Health. "We needed to be very compliant in a very short time period."
Because there would be a time gap between Joint Commission and DNV accreditation, Rosen worked with the state Department of Health and the local CMS office to keep it up to speed about the hospital's accreditation status.
Leaving The Joint Commission
After submitting the withdrawal notice, the Group Health hospital administrator received a call from The Joint Commission account representative to schedule an exit interview.
"Toward the end of the interview they wanted to know the actual date of withdrawal," says Rosen. The letter had said "immediately." Whatever date is specified for the withdrawal, The Joint Commission sends a notification to CMS to say that the facility is no longer subject to The Joint Commission accreditation. It was unclear what implications, if any, the notice to CMS might have concerning the hospital's continuing Medicare certification.
"Our understanding was that our [Joint Commission accreditation] certificate was effective through mid-March 2009," says Rosen.
According to The Joint Commission representative, the minute you withdraw, however, you go into non-accreditation status, she says. Which left the hospital in a quandary—if you do not withdraw immediately, you are still subject to a Joint Commission survey at any time, even if the hospital is in the process of changing to a different accreditation body.
"We were a little surprised at that," says Rosen. "So we reviewed the situation with our attorney and with our accreditation consultant at The Greeley Company, and were assured it was not a significant issue."
Once NIAHO accreditation has been achieved, the next step will be implementing the second component to DNV accreditation—use of ISO-9001.
"ISO-9001 is centered around quality," says Calise. "Industry has been doing it for a long time. It's looking at processes, making sure you're meeting the standards you're reaching for, and if not, adjusting them to make sure you do."