Promoting Quality and Patient Safety- the New Integrated Hospital Accreditation Program

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Hospital accreditation by a recognized quality certifier is an increasingly important way for hospitals to demonstrate their clinical expertise and commitment to patient safety. In the past accreditation has been seen as a ticket to trade instead of the strategic business asset that it can be. That is changing rapidly with the new NIAHO InternationalSM Hospital Accreditation which is based on DNV Healthcares hospital accreditation program approved by the US Centers for Medicare and Medicaid Services to accredit hospitals in the United States. This international accreditation is gaining acceptance in other countries around the world because of its ease of use and reputation for improving quality.


In the US independent accreditation is required by law for hospitals receiving reimbursements for government-insured patients (Medicare and Medicaid). Increasingly private insurance companies and other stakeholders are demanding successful accreditation as part of their contracts with hospitals. The Medicare mandate for accreditation was established in the 1960s and with the advent on new innovation from accrediting organizations like DNV is gaining stature as a symbol of quality not just an administrative responsibility.


One of the key drivers of the international expansion of hospital accreditation is patient mobility. More people are seeking to go outside their own country for medical procedures attracted by the quality access and cost advantages that are no longer defined by geographic boundaries. Adding to this trend are newly emerging pan-regional initiatives to improve access such as the European Unions Cross-border Healthcare Directive.


In turn healthcare providers realize they must not only communicate a level of clinical competence but also prove they have organization-wide quality procedures in place. Accreditation is an effective means for accomplishing that. It has the additional benefit of being a recognized discipline with elements of standardization that allow hospitals and citizens everywhere to understand its value.

Breaking New Ground

On September 26 2008 DNV Healthcare (DNVHC) was granted hospital deeming authority  the status to accredit hospitals  by the US Center for Medicare and Medicaid Services (CMS). DNVHC is a wholly owned subsidiary of Det Norske Veritas (DNV) an international autonomous foundation established in 1864 in Norway and operating in more than 100 countries. DNVHC corporate headquarters is in Houston Texas and its primary office for US accreditation is in Cincinnati Ohio.


Achieving hospital deeming authority was an historic feat for DNVHC which became the first new CMS-approved accreditor in 40 years.DNVs NIAHOSM hospital accreditation program consists of an accreditation standard that closely follows US Medicare Conditions of Participation and at the same time integrates the principles of the internationally recognized standard for quality management ISO 9001:2008 hence the acronym of the DNV - National Integrated Accreditation of Healthcare Organizations.


When adopting the principles of NIAHOSM internationally and forming NIAHO InternationalSM Accreditation DNV has found that the majority of the requirements of the standard are applicable globally and when there is a need to adopt a national requirement or regulation it is adopted as a country-specific measure.Within the NIAHOSM accreditation process hospital surveys are conducted annually they focus on observing the actions of caregivers but also enact an exhaustive review of written policies and procedures.


Herein lies the big difference in the DNV approach it places greatest emphasis on how things can be improved not on marking them as deficient. The process is rigorous but highly collaborative with DNV surveyors willing to share insights gained from other hospitals. Following a survey any findings of nonconformity to the NIAHOSM requirements must be addressed by the hospital which is responsible for preparing a corrective action plan and a tracking system to validate corrections.


The choice of ISO 9001 principles as the management system model for hospitals is not accidental. The continual improvement requirements which are the core of that standard make it the preferred quality system around the world adopted by complex businesses of all types. The key breakthrough made by DNVHC was finding a way to smoothly integrate the hospital-specific requirements from CMS with ISO so that the program operates uniformly without requiring extra time or staff from the hospital.


This combination has been also proven to teach hospitals the value of focusing on processes resulting in meeting and exceeding quality objectives set by the organization.This emphasis on continual improvement is also congruent with emerging trends that show hospitals adopting so called industrial quality management concepts borrowed from other sectors among them Aviation methodologies that include Lean and Six Sigma and naturally once hospital migrate to the more advanced quality management principles they embed the unique requirements of the NIAHOSM chapters into their system such that it truly becomes the hospitals way of doing business.


Hospitals adopting NIAHOSM universally report that it feels both new but also familiar at the same time which increases its acceptance across all departments and stakeholders within the hospital from administration to finance to clinical to boards of trustees.


The strong emphasis that DNV Accreditations places on the leaderships involvement that is supported by Management Reviews Internal Audits and Corrective and Preventive Measures which are closely echoed by similar points in the Medicare CoPs this integrated approach enabled the accredited hospitals to utilize accreditation as a vehicle to an effective stable and consistent pursuit of a sustainable improvement.This hospital accreditation program address 25 chapters (table 1)

How NIAHOSM Works

The first NIAHOSM chapter Quality Management System stipulates the need to adopt and comply with the principles espoused by ISO 9001 especially with the emphasis it places on Quality Management System The Management Responsibility Resource Management the Service Realization and the Measurement Analysis and Improvement requirements.


While there are quite a few hospitals around the world that have adopted the principles of ISO 9001 very often on the misconception lingers that it is a manufacturing standard not something invented for healthcare specifically. With the advent of the DNV NIAHOSM program however for the first time hospitals have a way to engage ISO in a uniquely healthcare package.


It is altering the old misperceptions about ISO and promoting new enthusiasm for a reliable continual quality tool that is recognized widely. Hospitals who do put in the effort and achieve full NIAHOSM accreditation become vocal proponents of ISO. It was an epiphany. We learned that not only could ISO be used by hospitals it should be used by hospitals Quality Director of Jordan Valley Medical Center Utah said.


It works better than any other quality system weve tried.DNVs understanding that implementing a quality management system in itself is a process is requesting its accredited hospitals to achieve compliance with the ISO 9001 principles in three years from first accreditation survey providing guidance during the subsequent years of servicing the hospital. Notably hospitals can and have achieved the compliance with these ISO 9001 principles faster.


An organization that selects DNV accreditation would undergo the initial steps of application and contracting. Once that is settled they would face the survey process.In addition to the standard itself NIAHOSM accreditation process is uniquely characterized by the following features that make it very useful to the hospitals:

  • The surveys are conducted annually resulting in a consistent standard which becomes the way hospitals conduct their business rather than having an accreditation process that is a mere preparing for an exam
  • The surveys focus on sequence and interactions of processes throughout the hospital enabling the medical and hospital staff to understand better the areas of high risk and enabling them to take necessary measures to mitigate this risk
  • The surveys do not include a tipping point in the process that results in varied levels of accreditation of the surveyed organization. Rather for any findings of nonconformity to the requirements the organization is responsible for preparing a corrective action plan to address these findings.

Once a hospital decides to adopt NIAHOSM accreditation concept it would undergo the initial steps of application and contracting. Once that is settled they would face the survey process.The survey team consists of three types of surveyors: Clinical Generalist and Physical Environment/Life Safety Specialist (PE/LSS). The Clinical surveyor must be either a medical doctor or a registered nurse.


The Generalist usually comes from a hospital administrative or managerial background. The PE/ LSS would have experience in hospitals life safety medical devices management infection control and/or Safety Health and Environmental (SHE) background. Using observation of services interviews tracer methodology the survey team will cover all aspects of hospital operations in accordance with the standards 25 chapters.


The training of the surveyors ensures that the qualified personnel are also competent and proficient in not only the subject matter they survey but also in the way NIAHOSM expects them to conduct such surveys. NIAHOSM expects each surveyor to attain what is known as the three Cs i.e. Consistent Collaboration and Cost effectiveness.

  • NIAHOSM surveys are annual. Barring any findings that impede patient safety the point of Jeopardy in line with the CMS requirements the survey findings fall into three types: Noteworthy efforts  where hospitals are doing well
  • Opportunities for improvement (OFI)  issues that do not constitute yet any breach of requirements but have been observed elsewhere to create an environment where such breaches may occur
  • Nonconformities where surveyors found issues that are out of compliance with NIAHOSM or ISO Requirements. Nonconformity must always show what the breach is and what the supporting objective evidence that demonstrate such breach is. There three types of nonconformities (table 2):

The absence of failure points coupled with the need for corrective/preventive action and their verification in the annual survey makes accreditation part of the hospitals normal workflow there is no need for special preparations for the survey as the hospital is at constant readiness. The gap analysis issued by DNV after the hospital is accredited to pinpoint current conditions and necessary improvements enables hospitals to realize that complying with these principles is much simpler than initially perceived by the hospitals.


After the three-year accreditation cycle the hospital would be also considered compliant with ISO 9001:2008.The testimonials the DNV accreditation receives from its accredited hospitals in the US Brazil and India reveal that the intent of the accreditation is indeed met. The benefits expressed by NIAHOSM accredited hospitals can be validated by contacting hospitals on the NIAHOSM reference hospitals gleaned from the NIAHOSM website (www.dnvaccreditation. com) can be summed in the following categories (table 3).


DNVHC accreditation labeled as a Breakthrough in US hospital accreditation is making its mark also on international accreditation scene. It has already begun to gain a relatively early but strong following and coupled with the experience that DNV gains from the risk management evaluation of the NHSLA in the UK is hoping to ensure hospitals learn not only how to manage risk and continually improve but also to enable hospitals to receive an objective rating based on its risk maturity model to the benefit of the patients and hospitals alike.


About the Author

Yehuda Dror is the President and CEO of DNV Healthcare Inc. the first new hospital Accreditation Organization approved by the US Centers for Medicare and Medicaid Services (CMS) in the last 40 years. Trained as an engineer (MS from Massachusetts Institute of Technology) and business manager (Executive MBA from University Houston) Yehuda has more than 30 years experience in developing and implementing services that safeguard life property and the environment. For additional information Yehuda Dror can be reached at DNV Healthcare Inc 1400 Ravello Drive Katy TX 77449. Phone: +1 281 396 1869 Mobile: +1 281 685 9996 Fax: +1 281 396 1903 Web: www.dnvaccreditation.c