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Update: NIAHO certification program

Hello,

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.

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.

TJC, DNV, and HFAP all to speak at conference

We’ve now confirmed speakers from The Joint Commission, DNV Healthcare, and HFAP for the May 2009 conference. Should be a great conference!

Who’s making the switch?

In the upcoming issue of Briefings on The Joint Commission, I was able to talk with accreditation professionals at two hospitals who have applied for and been surveyed by DNV and intend to leave The Joint Commission as soon as their DNV application is approved. The conversations left me curious–how many of our members here at AHAP are looking at DNV’s accreditation process as a possible alternative?

My question to the field is–are you going through any sort of process, formal or informal, to take a look at DNV as an alternative? Has anyone decided to make the switch? What factored into the decision (for or against changing accrediting organizations)?

Speakers for 3rd Annual AHAP conference

Just wanted to follow up on Matt’s posting and offer some details on our 2009 conference. We’ve already confirmed the following speakers and topics:

Tracers: Jodi L. Eisenberg, MHA, CPMSM, CPHQ, CSHA, chair of the AHAP advisory board and program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago, and Jean Clark, RHIA, CSHA, member of the AHAP advisory board and service line director for health information management at Roper St. Francis Healthcare in Charleston, SC
Making the NPSGs come to life: Patricia Pejakovich, RN, BSN, MPA, CPHQ, CSHA, and WendySue Woods, RN, MHSA, CSHA, senior consultants with The Greeley Company, a division of HCPro
Leadership standards: Ken Rohde, senior consultant with The Greeley Company, a division of HCPro
Joint Commission alternatives: Patrick Horine, executive vice president of accreditation at DNV Healthcare, Inc. (we’ve also invited representatives from The Joint Commission and HFAP)
Critical test results 2.0: Gayla Jackson, RN, BSN, member of the AHAP advisory board and a practicing nurse manager at Mount Auburn Hospital in Cambridge, MA
Scoring: Kurt Patton, MS, president of Patton Healthcare Consulting, LLC, and former executive director of accreditation services for The Joint Commission
Survey readiness: Lisa Eddy, RN, CPHQ, CSHA, senior consultant for The Greeley Company, a division of HCPro
Suicide risk assessment: Sharon Chaput RN, CSHA, member of the AHAP advisory board and director of regulatory and quality management at Brattleboro Retreat in Brattleboro, VT
As Matt mentioned, we will be providing more details on the conference, which will take place May 14-15 in Las Vegas. Make sure to keep an eye on this blog in the comings days and weeks.
And, as always, you can sign up for the conference here.
Hope to see you all in Vegas!

DNV on the Web

Hello,

Thought this might be of interest to our members: healthcare lawyer and consultant David Harlow posted in his blog yesterday about potential benefits and costs to moving to DNV’s NIAHO program for hospital accreditation. Even more interesting, though, is that his post received direct feedback from DNV in the form of a reply by Executive Vice President Darrel Scott.

Scott responded directly to issues about rumored confusion about insurance companies and the NIAHO program, and clarified the timeframe in which a hospital must become ISO-9001 compliant upon entering the NIAHO accreditation program (within two years of their first accreditation effective date).

Looks like DNV is monitoring what folks are saying in the field. Have any of you started exploring the option of changing accrediting organizations in the future? What sort of questions are you hoping to have answered about DNV, NIAHO, and ISO-9001?

CMS approves DNV application to accredit hospitals

Hello, everyone. I just wanted to update you on a developing story:

The Centers for Medicare and Medicaid Services (CMS) announced Friday the approval of DNV Healthcare, Inc. as a deeming authority for U.S. hospitals. DNV is the first new organization to receive deeming authority for hospitals in more than 30 years.

According to the pre-Federal Register announcement, DNV was recognized “as a national accreditation program for hospitals seeking to participate in the Medicare or Medicaid programs” effective September 26, 2008 through September 26, 2012.

“We’re coming into this business not just as another option,” says Yehuda Dror, president of DNV Healthcare. “We want to take a leadership position.”

“I think a lot of people will explore the possibility,” says Bud Pate, REHS, is Vice President for Content and Development for The Greeley Company; a division of HCPro, Inc. “There are some hurdles that people will need to walk through—since DNV is new they’re going to need to work through some residency issues, contract issues, that may exist and may mention The Joint Commission but none of these are insurmountable.”

DNV has crafted a system intended to combine CMS Conditions of Participation (CoP) with ISO 9001 quality management. This program, called the National Integrated Accreditation for Healthcare Organizations or NIAHO(SM), was created to make the accreditation process more streamlined as well as identify means for improving current standards and promoting continual improvement.

“The ISO-9001 certification seems to be a logical progression to the focus on quality assurance and quality improvement that has occurred in healthcare, primarily in hospitals,” says Larry Poniatowski, RN, BSN, CSHA, principal consultant for Accreditation Compliance Services with The University HealthSystem Consortium. “The issue here now will be to see how well it’s embraced by hospitals.”

Twenty seven U.S. hospitals in 22 states have been accredited by DNV Healthcare using the NIAHO(SM) program in addition to other accreditation services.

In mid-2007, DNV Healthcare acquired Cincinnati-based TUV Healthcare Specialists with the belief that the acquisition would help cement DNV’s application to CMS. In 2006, TUV had unsuccessfully applied for deeming authority.

DNV Healthcare is a division of Houston-based DNV USA, a subsidiary of the Norwegian company Det Norske Veritas. DNV focuses on risk management and training in several industries, including healthcare.

We’ll be providing additional coverage here on the blog as well as in Briefings on The Joint Commission in the upcoming issue.

What is your sense of DNV’s chances? Is your facility considering looking into moving away from Joint Commission accreditation? Are you interested in further details on how DNV’s process works?