Editor’s Note: This week’s CSA Online First is written by Laura Dew, MD, a member of our sister society, the Texas Society of Anesthesiologists. Dr. Dew serves on the Quality Management and Departmental Administration Committee of the ASA and is the ASA’s liaison to DNV. She is CEO of MHA Division and Chairman CQI and Clinical Operations Committee of Greater Houston Anesthesiology, US Anesthesia Partners. We believe it will be useful for our members to know about an alternative to The Joint Commission for hospital accreditation, since DNV has only recently started working in this arena.
Watch out Joint Commission, there’s a new accreditor in town…
by Laura Dew, MD
For over 40 years there has been one sheriff in town when a hospital needed accreditation. In 2008, there was a game changing event: CMS gave deeming status to DNV Healthcare to accredit US hospitals. This was the first time The Joint Commission (TJC) had a serious contender in their world.
I became aware of DNV Healthcare (DNVHC) when my very large Texas hospital system built its fifth hospital in suburban Houston. It opened in December 2010. The hospital system contacted TJC to request a survey to become accredited and TJC said they would be there sometime prior to March 2011. As there was significant capital expenditure, there was a serious interest in getting the hospital accredited ASAP – waiting until March 2011 was not an option. One of the administrators suggested DNV as an alternative. (The rest of the hospital system’s other four hospitals were all accredited by TJC). So after some rigorous research the C-suite decided to ask DNV to come survey the hospital. DNV said they would be able to be there in December.
The plan was to get the initial accreditation with DNV and then proceed with the usual TJC accreditation, but the experience of the DNV accreditation process was so positive that the decision was made to continue with DNV accreditation at this new hospital and not invite TJC. In fact, the executives were so impressed they made a surprising decision to move the entire hospital system to the new accreditation agency. All the hospitals would switch to DNV Healthcare and ISO 9001 as their time to renew came due. This was a huge paradigm shift.
Who is DNV Healthcare?
DNV Healthcare is a wholly owned subsidiary of Det Norske Veritas. DNV is a Norwegian company that has been managing risk since 1864 – initially for large maritime vessels. They are a global provider of risk management and quality management in ten industries (including healthcare) worldwide in over 100 countries.
In Dec 2007, DNV Healthcare applied to CMS for deeming authority. In a surprising move, in July 2008, CMS removed TJC’s statutory authority and required all agencies to apply for deeming status including TJC. (This had been suggested by the GAO to Congress).
What is so different about DNV accreditation?
NIAHO® standards integrate requirements based on the CMS Conditions of Participation (CoPs) with the internationally recognized ISO 9001 Standards. DNV Healthcare’s NIAHO standards and Interpretive Guidelines can be downloaded for free from the Internet. The integration of ISO 9001 provides the framework for a sustainable CoP implementation. ISO 9001 standards allow a hospital to use its combined knowledge, wisdom and innovation to improve quality and safety. ISO 9001 is the framework within which methodologies such as LEAN and Six Sigma are better understood and utilized. The combined result is intended to drive quality transformation into the organization’s core processes.
DNVHC’s accreditation style utilizes the hospital’s own quality program, individuality and innovation. DNVHC Accreditation Requirements are consistent with the CMS Conditions of Participation, allowing for more consistency in complying with the CoPs and being continually prepared for accreditation surveys.
The initial survey is based on CMS’s CoP and after that there is an introduction of the ISO Quality Management System Infrastructure. Hospitals have to be compliant with ISO 9001 within 3 years (OPTIONAL ISO 9001 Certification). DNVHC Annual Surveys are intended to lead to more sustainable, consistent, effective accreditation. There is an added accountability – hospitals are prepared to be “survey ready.”
As I see it, there is a culture change in hospitals regarding the approach to accreditation, and improving the use of resources within the organization. The focus has shifted from gaining accreditation, to a goal of constantly improving quality. Accreditation becomes a management asset for quality and patient safety improvement as opposed to a burden. This leads to improvement of patient safety and a reduction in a hospital’s internal cost of accreditation.
How does DNV help?
There is less change to adopt, from year to year or survey to survey, and DNVHC provides survey tools to help with the process. The process is intended to be very transparent by following the CMS CoP. The entire process aims to be collaborative and performance based, rather than prescriptive. This is particularly true in the spirit of the survey team, which strives to be collaborative instead of fault-seeking. Continuity is also a goal of this program: at least one surveyor will be the same as the year before, and they will look to see where you have progressed and improved. There is no tipping point; No specific number of findings will jeopardize a hospital’s accreditation status.
Currently, three of the five hospitals in my large hospital system have become accredited by DNV Healthcare with two remaining. It appears to me that the staff is on board. The accreditation team at each hospital is excited to be continually focusing on quality improvement; there is more openness and less fear than in the past. The goal of improving patient safety and continual improvement of quality in a measured process is the philosophy of DNV Healthcare and my hospitals share the philosophy.