December 17, 2008 | | Comments 0
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Update: NIAHO certification program


I just wanted to share a snippet from a recent article in Briefings on The Joint Commission about a pair of hospitals which have switched to DNV, Inc.’s accreditation program. The following explains a bit about the NIAHO survey process. Hope this is of interest.

Six surveyors showed up at Citizens Medical Center (Victoria, TX) for what would end up being a three-day survey. They were presented with a list of documents to present for review, along with a tentative three-day schedule. As part of prior preparation, the documentation was quickly pulled and presented.

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The survey consisted of document reviews and discussions, review of open patient records, interviews with staff, life safety tours, and more.

“All in all, the survey was very thorough, comprehensive, collaborative, and educational,” says Caren Adamson, assistant administrator at Citizens Medical Center. “We were held accountable to the prescriptive requirements of the CoPs and were assessed with our compliance with the ISO standards and our underlying framework for ongoing compliance.”

Purdy has found that the survey process for her facility has been a less stressful process for staff.

“They make it clear they’re looking at the process, not the individual,” says Judith Purdy, RN, risk/quality director at Hays (KS) Medical Center. “The staff appreciate that.

It’s not so much a new survey process,” says Purdy. “They survey the CoPs. The hospital is very familiar with those and comfortable being surveyed by those standards.”

Staff is trained in the CoPs and very aware of those standards, she explains.

“We’ve been talking to the employees for over a year that this is the agency we’re looking towards shifting to. They’ve been hearing this information for months,” says Purdy. “There is a sense of anticipation waiting for this to really happen.”

Purdy also noted there will likely be a learning curve on both sides of the survey process at first.

“To some degree they’re still training the surveyors, but as a rule there will be a generalist, a clinical person and a life safety person,” says Purdy. This list does not necessarily include a physician, and the generalist can fulfill a clinical or nonclinical role or both and will be trained in the standards to do so.

DNV has stated that they will attempt to send the same surveyors each year, with the thought that the survey process will benefit from a surveyor that has a level of knowledge about the facility and how it functions and operates.

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About the Author: Matt Phillion is the director of the Association for Healthcare Accreditation Professionals and a Senior Managing Editor at HCPro, Inc., where he is the editor of the monthly publication Briefings on The Joint Commission.

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