Volume 25, Issue 2
WATCH OUT JOINT COMMISSION THERE’S A NEW ACCREDITOR IN TOWN...
The following article has been modified and reprinted with permission from the CSA first Published March 2013.
Laura Dew, MD
ASA Alt. Delegate
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 Det Norske Veritas (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 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 proceed with 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 expand to the entire hospital system. All the hospitals would switch to DNV Healthcare and ISO 9001 as their time to renew came due.
Who is DNV Healthcare?
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.
What is so different about DNV accreditation? National Integrated Accreditation for Healthcare (NIAHO®) standards integrate requirements based on the CMS Conditions of Participation (CoPs) with the International Organization for Standardization (ISO) 9001 Quality Management System. This integration provides the framework for a sustainable CoP implementation. ISO 9001 allows 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.
DNV’s accreditation style utilizes the hospital’s own quality program, individuality, and innovation. DNV Accreditation Requirements are consistent with the CMS’s CoP, allowing for improved compliance and constant readiness 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. Hospitals have to be compliant with ISO 9001 within 3 years (OPTIONAL ISO 9001 Certification). DNV Annual Surveys are intended to lead to more sustainable, consistent, effective accreditation.
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
