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Medical Staffs Benefit from DNV's Educational Approach to Accreditation Surveys

Liz Jones, August 10, 2009

Until recently, hospitals have had few options for accreditation surveys: The Joint Commission or their respective state boards. Since the Centers for Medicare & Medicaid Services granted deeming status to Det Norske Veritas (DNV Healthcare) in late 2008, folks in the field have been itching to know what makes this accreditor different.

DNV looks for the same things the Joint Commission does—both are tasked by CMS to ensure that hospitals comply with its Conditions of Participation. However, DNV takes an entirely different approach to conducting surveys that DNV-accredited facilities find effective and even friendly. "We might be easier to get along with, but we are not easy," says Patrick Horine, executive vice president of accreditation at DNV Healthcare in Cincinnati.

DNV's accreditation program, called the National Integrated Accreditation for Healthcare Organizations (NIAHOSM), incorporates International Organization of Standardization (referred to as ISO) 9001 quality management standards. ISO 9001 standards require hospitals to document and analyze root causes of poor outcomes, follow through with changes to improve performance and correct inconsistencies, and document preventive and corrective actions—in other words, the focus is on continuous improvement rather than erratic scrambling to "fix" things before an accreditor arrives at the door.

Incorporating ISO quality standards into the survey process calls for yearly surveys, and people don't seem to mind. Judith Purdy, RN, previously the director of quality at Hays (KS) Medical Center who recently retired and will soon work with DNV Healthcare as a surveyor, says the yearly surveys keep medical staffs on track. "Regardless of how good a hospital's intentions are to stay in compliance, people do tend to let things lapse if [they] know [they] aren't being surveyed again for three years."

The whole process of surveying the medical staff services department takes about 90 minutes to two hours, says Horine.

Holland (MI) Hospital was surveyed at the end of April, and Lana Heavilin, RN, medical staff office coordinator, recalls spending about 40 minutes with a physician surveyor reviewing the medical staff bylaws. The reviewer had read the bylaws the day before the medical staff services department was surveyed and came prepared with specific questions. The surveyor also requested the credentials files for an active medical staff member, an AHP, a non-admitting affiliate physician, and a surgeon.

"He gave us positive feedback through the whole thing," says Heavilin.

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