Healthcare accreditation has many benefits for an organization but choosing the right agency can be challenging. Accreditation to a health care organization stimulates continuous improvement. It enables the organization in demonstrating commitment to quality care. It raises community confidence in the services provided by the health care organization and provides opportunity for healthcare organizations to benchmark with the best. The goal of healthcare accreditation is to ensure that organizations meet acceptable levels of quality. Accreditation in the United States involves non-governmental entities (accrediting organizations) as well as federal and state government agencies. Healthcare facilities have the opportunity to choose between a few options, The Joint Commission (www.jointcommission.org), DNV (www.dnv.com), Center for Improvement in Healthcare Quality (www.cihq.org), and CMS (https://www.cms.gov) are the primary options for hospitals accreditation needs, as well as other healthcare organizations.
Does your current accrediting body’s philosophy and approach align with your organization’s goals? Are you and your team able to keep up with the standards set forth by your accrediting agency? For over 27 years Courtemanche & Associates has been serving the healthcare community in navigating the course for regulatory compliance and success. Our consultants are educated and trained to provide your organization assistance in all areas of accreditation. This month we would like to outline the pros and cons of DNV healthcare accreditation.
Who is DNV?
DNV (Det Norske Veritas) was established in 1864 in Oslo, Norway and has been operating in the United States since 1898. DNV’s purpose is safeguarding life, property, and the environment. DNV has a worldwide reputation for quality and integrity in certification, standards development, and risk management over a wide range of industries, including extensive international healthcare experience. On September 26, 2008, the US Centers for Medicare and Medicaid (CMS) approved DNV Healthcare (DNVHC) by granting it deeming authority for hospitals. Any hospital accredited by DNVHC after that date is deemed to be in compliance with the Medicare Conditions of Participation (CoP).
DNV’s vision is to be a trusted voice to tackle global transformations. Its values are beliefs that shape our performance; these ideals are the behaviors expected of all employees in DNV:
- To care for each other, our customers, our planet, and we take care of ourselves.
- To dare to explore, to experiment, to be different, and to be courageous, curious, and creative.
- To share our experience and knowledge. We collaborate with each other and our customers, and we continue to grow and develop as a result.
What is DNV’s Role in Healthcare Accreditation?
DNV surveys and accredits organizations in the ISO 9001 (International Organization for Standardization) and NIAHO Standards (National Integrated Accreditation for Healthcare Organizations). The ISO 9001 Standards provide the framework for a sustainable regulatory compliance, allows organizations to use its combined knowledge, wisdom, and innovation to improve quality and safety, and is the framework within which methodologies such as LEAN and Six Sigma are better understood and utilized. All these together drive quality transformation into the organization’s core processes. The NIAHO Standards are based on the CMS Conditions of Participation.
ISO 9001’s quality management system is able to improve overall performance and sustainability. By doing so you will be able to consistently deliver patient care and services that meet the regulatory requirements therefore enhancing customer satisfaction. ISO 9001 allows you to address risks and opportunities for improvement. DNV uses a process approach, incorporating Plan-Do-Check-ACT (PDCA) and risk-based thinking. This approach allows an organization to plan its processes and its interactions. It allows an organization to ensure that its processes are resourced and managed, and that opportunities for improvement are determined and acted on.
Consistent and predictable results are achieved more effectively when activities are understood and managed as interrelated processes that function as a coherent system.
Risk-based thinking assists organizations to determine the factors that could cause its processes and its quality management system to deviate from the planned results, to put in place preventative controls to minimize negative effects and to make maximum use of opportunities that arise. The objectives of risk-based thinking in a hospital setting are as follows: to provide confidence in the organizations ability to consistently provide patients with the best possible care by addressing potential risks, enhance patient satisfaction, and exceed expectations. IOS 9001 brings risk-based thinking front and center and helps to identify opportunities which can be considered the positive side of risk.
How is Healthcare Accreditation Achieved?
To achieve healthcare accreditation with DNV you will go through a process different from other accrediting agencies.
- During the initial visit you will gain accreditation to NIAHO (meet the requirement for CMS) and be provided with an ISO 9001 introduction and education: compliance, or certification within three years.
- During visit two (one year after accreditation) you will continue accreditation by undergoing a survey to NIAHO and a survey for progress in implementing ISO 9001.
- During the third visit (two years after accreditation) you will again continue accreditation by undergoing a survey to NIAHO and continue to work toward ISO 9001 implementation.
- During the fourth visit (three years after accreditation) you will have a NIAHO survey, and it is the last year to achieve ISO 9001 compliance/certification. If you are in compliance with ISO 9001 a statement will be included on your Certificate of Accreditation.
In summary, choosing an accrediting agency for your organization is challenging. You need to review all the websites and decide what works best for your organization. The agencies mentioned are all based on the CMS standards with an addition of standards specific to the accrediting agency. DNV is unique in that they have their ISO 9001 standards separated out from the NIAHO (CMS CoPs) and visit more frequently that the others.
For more information on how the C&A team can assist you with healthcare accreditation and regulatory compliance visit us at https://www.courtemanche-assocs.com/services/survey-readiness/ Better Compliance, Better Care.
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