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.
Heavilin was also surprised that the DNV surveyors invited her and everyone else who participated in the survey to the final survey meeting. "I heard right from the person who surveyed us what he thought we had problems with. I thought it was interesting that they opened up the meeting to everyone, not just administration."
Heavilin found the process to be educational rather than nerve wracking, and Horine attributes that to the fact that DNV surveyors are qualified based on their education, background, and experience, but they are hired for their communication skills.
"The DNV really wants to help hospitals, which I think put the staff at ease," Purdy says of Hays Medical Center's survey in October 2008. "Staff seems more willing to talk about areas where they think some improvements could be made."
Horine says that although DNV prides itself on its education approach to accreditation surveys, surveyors do not act as consultants by any means. "We can provide best practices, share information learned from other hospitals, and give some general guidance as to how to go about addressing corrective actions, but it is important to relay that we don't consult or certify our own work," he says.