dnv accreditation vs joint commission
2010 Mosby, Inc. I've just been hired on at a hospital that is Det Norske Veritas (DNV) accredited as opposed to the Joint Commission. What is hospital accreditation The accreditation programs DNV offers either directly address regulatory requirements for hospitals, such as US Government's Centers for Medicare and Medicaid (CMS), or provide guidance and best practices for clinical specialty organizations across healthcare. DNVs NIAHO standards is approved by CMS. 4NuH.z)z06q?Rt|E"vzQV-\\-U=^4/M6z`| Y, 2mKe59\^9xg6`?,^eaQ)PHwzX=ixf#`x[aA;B|A3 $z(Gc(A%aC@)4"44SY S20L: 2("ukvVhMg9a,"J0$8 1sb s6s[fPE<1I!4XOLv^+d2(i}%C9X Biocor Hospital De Doencas Cardiovasculares LTDA. At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. (Are minimal standards sufficient in todays healthcare climate? ) H\J@{6fgBA[^Hi M}{voI\]fcuvO1}yPYq:\xvwm,.rsi`at3Xvizx)vnn. Before the actual certification audit, we will normally make a preliminary visit to your organisation. 0000006234 00000 n Rochester Regional Health is a national leader with the most Beacon Awards from the American Association of Critical Care Nurses, recognizing hospital units that have integrated evidence-based practices to improve patient and family outcomes. Although the costs of Joint Commission and DNV are about the same, according to health experts, there are some big differences between the two: The organization surveys the hospitals that use their commissioning services annually, while the Joint Commission extends its survey periods from 18 months to three years. To fulfill the accreditation criteria, an accrediting authority assesses the certification body/registrar to verify that the certification body/registrar complies with existing requirements. Infection Control & Hospital Epidemiology (2020), 41, 13441347. Driven by its purpose, to safeguard life, property, and the environment, DNV helps tackle the challenges and global transformations facing its customers and the world today and is a trusted voice for many of the worlds most successful and forward-thinking companies. 2002 Jun;75(6):1179-82. doi: 10.1016/s0001-2092(06)61621-9. Accessed August 5, 2009. The International Standards Organization (ISO) Web site. Accepted manuscript, pp. To check your readiness for the certification audit, i.e. Vendor Login | to review your manual, check procedures, to see your facilities, and briefly check the implementation of your management system. This collaborative approach is crucial in continuing to improve and be a quality improvement hospital. WebDNV offers a number of standards - Hospital Accreditation, Stroke Center, Orthopedic Service Line, Infection Risk and more. More than 2,100 individuals are employed throughout health system and approximately 125 providers representing 28 medical specialties provide care to patients. See upcoming training courses. endstream endobj 138 0 obj <>stream 0000001631 00000 n [lW7wI/_./-";)n*R+lx-I$,4|t*0#__ l) Fundao So Francisco Xavier / Hospital Mrcio Cunha. Psychiatric Hospitals are accredited for a three year period, subject to annual survey to verify continuing compliance with NIAHO. PMID: 12085409 Joint Commission on Accreditation of Healthcare Organizations* / history 0000003710 00000 n ISO standards ensure that products and services are safe, reliable and of good quality. For more information about DNV, visit www.dnvcert.com/healthcare. DNV: Det Norske Veritas: DNV: Der Norske Veritas: DNV: District of North Vancouver (British WebIn addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. DNVs accreditation program, called NIAHO (Integrated Accreditation of Healthcare Organizations), involves annual hospital surveys instead of every three years and encourages hospitals to openly share information across departments and to discover improvements in clinical workflows and safety protocols. As an example, a hospital could have its Joint Commission accreditation renewed for three years on July 10, 2010. To review focus area input and agree on one to three particular focus areas upon which the audit will focus. DNV has a transparent procedure for suspension or withdrawal of certificates. WebCommission, Healthcare Facilities Accreditation Program (HFAP) and Det Norske Veritas Healthcare, Inc. (DNV) for hospitals; gives deeming authority to NCQA for Medicare Advantage health plans Accrediting Organizations Targets for Accreditation Types of Standards Accreditation Categories NCQA Joint Commission Health plans DOI:https://doi.org/10.1017/ice.2020.1437. The documentation review report summarizes any findings from this process. 0000001195 00000 n 0000000913 00000 n <]>> The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. We focus on achieving this aspect at every survey. The DNV program is consistent with our long-term commitment to quality and patient safety, says Dr. Teresa Camp-Rogers, Chief Quality Officer at SCRMC. SCRMC serves as the second largest employer in Jones County. endstream endobj startxref Our lead auditor evaluates your management system documentation. At least one periodic audit per year is required. Accessed August 5, 2009. Reflective of an organizations performance with respect to Joint Commission standards and elements of performance (EPs).Transparent all components of the process are fully disclosed to accredited and certified organizations.Easily understood by all involved parties.More items <>stream These surveys, often routine or planned to certify our specialty programs, look at our communication processes, governance, processes, standardization, safety precautions and outcomes. org 22, Questions to Consider Will our reputation in the community suffer if we change? To update your cookie settings, please visit the. Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? Clifton Springs Hospital and Clinic recently was awarded an A grade for safety. HSMo0+TR E9dR-,Q Employee Login | Today, 300 follow DNV Accreditation procedures, and 80 more are in the process This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. 121 0 obj xref WebThis background is fascinating in view of The Joint Commissions (TJC) history. Comparison of Joint Commission and DNV - GL HC NIAHO MS Standards Kathy Matzka, CPMSM, CPCS 8 22 Resources Standards: NIAHO Standards, We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. 0000005251 00000 n In 2020, Rochester Regional Health participated in 123 regulatory surveys in our acute care settings, outpatient settings and specialty programs from compliance agencies like DNV Healthcare, The Joint Commission and the Department of Health. View our list of disease-specific and specialty program certifications. DNVs philosophy is to assist Psychiatric Hospitals through compliance with the NIAHO Hospital Accreditation Program and Appendix B standards, encouraging a safe and therapeutic milieu which allows patients to be treated safely and effectively. We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. 0000004698 00000 n WebAccredited hospitals. South Central was the first DNV accredited healthcare organization in Mississippi. Brazil. Antibiotic Susceptibility | ISO is the International Organization for Standardization. The focus areas should be linked to the management system and reflect the risks or opportunities that are most important to you. WebAssistant Director - Accreditation Services . x- [ 0}y)7ta>jT7@t`q2&6ZL?_yxg)zLU*uSkSeO4?c. R -25 S>Vd`rn~Y&+`;A4 A9 =-tl`;~p Gp| [`L` "AYA+Cb(R, *T2B- xbbg`b``3E0 ) WebWe have a variety of resources to help you explore and master the accreditation process. Knowing where to focus improvement efforts is critical to take control of risk elements that can threaten your business success. We use cookies to help provide and enhance our service and tailor content. The scope of certification is agreed at an early stage in the certification process. This product includes updates that will be made by NAMSS over the next 12 months. 0000007824 00000 n Available at: www.iso.org/iso/home. Risk Based Certification is our exclusive approach to all management system certification. This is applicable in situations where an organisation persistently and seriously fails to maintain compliance with the management system standard or due to other situations, as defined in the procedure for suspension and withdrawal of certificates. All rights reserved. Read Part 3: Accreditation Options: Understanding the Joint Commission DNV Healthcare originated in Norway in 1864 as a risk management company. endstream endobj 1331 0 obj <>stream All Rochester Regional Health labor and delivery hospitals. You must complete the Participant's Agreement in order to access your purchased NAMSS Education. SCRMCs current service area includes a patient population of 120,000 residents in 4 countiesJones, Jasper, Smith and Wayne Counties. %,,`0,XA!rd{ey` F7 Hospitals are no longer stuck in a cycle of addressing the same issue every three years. v4?fBHQ [C. WebDNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. David Eickemeyer, MBA; Associate Director, Hospital Business Development. DNV has accredited about 300 hospitals with another 80 or so awaiting accreditation, according to Horine. Innovative hospitals have started embracing ISO as a way to identify and focus on the most successful approaches to patient care, billing and other critical aspects of running a modern hospital system. Please enter a term before submitting your search. Our Privacy Policy | Blood use Prescribing of medications Surgical Case Review Specific departmental indicators Moderate Sedation Outcomes Anesthesia events Appropriateness of care for noninvasive procedures/interventions Utilization data Significant deviations from established standards of practice Timely and legible completion of patients medical records Variants analyzed for statistical significance 19, Addressed by TJC, Not NIAHO Verification of applicant identity Use of CVO (DNV does allow is addressed under telemedicine) Health status (DNV only under surgical privileges) Applicant required to provide info re: previously successful or currently pending challenges to licensure or voluntary relinquishment, felony convictions Leadership standards place additional responsibilities on MS Residency program requirements 20, Addressed by NIAHO, not TJC Receipt of database profile from OIG Medicare/Medicaid Exclusions initial/reappointment/temporary privileges 21, Resources Standards: NIAHO Standards, Interpretive Guidelines, or Accreditation Process www. During surveys, DNV wants to see the improvements that have been made as a result of the annual survey process. 0000003960 00000 n South Central is a public, not for profit hospital owned by Jones County, MS, who has an economic impact to our local community annually of almost $200 million. %PDF-1.6 0000020794 00000 n Hover over the "Register" button in the top right corner to see the price, 1 Question|Unlimited attempts|1/1 points to pass|Graded as Pass/Fail. com Jointcomission. The password to view the NAMSS Comparison of Accreditation Standards is: Q7r&Km Accreditation Canada accredited its first organization internationally in 1967 in Bermuda. 8667 0 obj <>stream This is the authorities way of auditing the auditors, such as certification bodies like DNV. WebThis electronic reference tool provides plain-language interpretations of the credentialing standards for The Joint Commission, NCQA, Healthcare Facilities Accreditation Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. 8618 0 obj <> endobj Felicio Rocho Hospital. Centers for Medicare and Medicaid Services. Delia Constanzo . The documentation review can be performed prior to or conducted as part of the initial visit. Senior Account Executive . 0 % Midland Memorial happy with DNV shift. 0000004038 00000 n This decision is made based on a review of the certification process and associated documentation. Thats where ISO 9001 comes into play and turns the typical get-your-ticket-punched accreditation exercise into a quality transformation.. 0000000016 00000 n hb```b``c`201 +s0 The Joint Commission (TJC) is a non-profit organization that accredits and certifies over 22,000 healthcare organizations and programs in the United States. LAUREL, MS, South Central Regional Medical Center (SCRMC) announces the successful completion of its new accreditation process that has been awarded by DNV. %PDF-1.6 % When found compliant, we issue the certificate. Infection Control & Hospital Epidemiology. Webparticipation was based on Joint Commission accreditation issued prior to that date will continue to participate in Medicare via deemed status until the normal expiration date of its accreditation. endstream endobj startxref wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 Below are several components of our psychiatric hospital accreditation program. Public Records Policy | Accreditation can directly affect the quality of hospital care. 127 30 TCI certification. 0000013305 00000 n As with all accreditation programs, surveyors from the organization will visit the hospital on regular annual intervals to monitor the organizations progress in implementing the new requirements. After each survey there is a detailed report which is easy to follow and describes, with objective evidence, where your organization is not in compliance with the standard. As DNV hospitals often say, ISO provides the structure for the staff to focus on We have taken an entirely different approach to accreditation, and hospitals are really responding, says DNV Healthcare USA Inc. President Patrick Horine. endstream endobj 8619 0 obj <>/Metadata 315 0 R/Outlines 731 0 R/Pages 8594 0 R/StructTreeRoot 1070 0 R/Type/Catalog>> endobj 8620 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 8621 0 obj <>stream Using an accredited third party certification body/registrars demonstrates that the auditing company is meets the required quality standard set by the accrediting authority. Agreeing on focus areas is a collaborative effort, and our auditors can help suggest focus areas if necessary. Certification by DNV Healthcare is key step toward establishing your hospital's reputation for excellence. The important role of the Joint Commission AORN J. DET NORSKE VERITAS (DNV) 1 27. hTkSI?ssMl Our Risk Based Certification approach tailors the process to evaluate your select business risks in addition to compliance with the standards requirements. DNV Healthcare, Joint Commission emphasize differences. 0 Accessed April 27, 2010. WebThe more variables and inter-dependencies in you organization, the more relevant ISO becomes. Accredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. endstream endobj 139 0 obj <>stream 0000003466 00000 n Because there would be a time gap between Joint Commission and DNV accreditation, Rosen worked with the state Department of Health and the local CMS WebOne of the large number of accreditation schemes in the United States, the Joint Commission (TJC) currently being the best known, has created Joint Commission International, or JCI. There is always an opportunity to improve. Whether certifying a companys management system or products, accrediting hospitals, providing training, assessing supply chains or digital assets, DNV enables customers and stakeholders to make critical decisions with confidence, continually improve and realize long-term strategic goals sustainably. In recent years, DNV have been challenging TJC in the USA. Lesho, E., Hix, J., Bronstein, M., Shastry, S., Hanna, J., Scroggins, G., & Grieff, M. (2019). After the audit you need to address and respond to non-conformities within an agreed deadline. 0000001372 00000 n %PDF-1.6 % 0000007461 00000 n Country-wide, more than 5000 hospitals are permitted to provide Medicarefinanced services solely Learning happens when staff are comfortable and not intimidated by the process. "F$H:R!zFQd?r9\A&GrQhE]a4zBgE#H *B=0HIpp0MxJ$D1D, VKYdE"EI2EBGt4MzNr!YK ?%_&#(0J:EAiQ(()WT6U@P+!~mDe!hh/']B/?a0nhF!X8kc&5S6lIa2cKMA!E#dV(kel }}Cq9 It is widely recognized as the gold standard in healthcare accreditation, and its standards are considered rigorous and comprehensive. Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf. This is a list of the hospitals accredited to the international standard by DNV. Lab Specimen Guideline | A successful management system is one that is improved on a continual basis. Based on a positive outcome, he/she will recommend certification. [fy^Mx_6vbvX,'Mqtr)yzQn.^%~&PdXfbpqxu5Y)Vwuq_DO1ou{)v]tiply/m}+s[(E}Zyc"F%x.%i%NW?VE\gcuJ[Q[Ka/.W. Organizations seeking CMS approval may choose to be surveyed either by an accrediting body, such as the Joint Commission, DNV, and HFAP, or by state surveyors on behalf of CMS. This commitment to safe, reliable and high-quality care is also demonstrated through our regulatory compliance and accreditations, awards and recognition and participation in national conferences and journals. DNV has a client drop box feature where questions regarding the standards can be asked directly to our specialists and surveyors. DOI: https://doi.org/10.1016/j.mnl.2009.10.004, The International Organization for Standardization (ISO), To read this article in full you will need to make a payment. Medical Student H&P | The Joint Commission Lon Berkeley . Provides a framework for organizational structure and management Accreditation involves preparing for a survey and maintaining a high level of quality and compliance with the latest standards. Joint Commission accreditation provides guidance to an organizations quality improvement efforts. 630-792-5787 | lberkeley@jointcommission.org. We provide services at more than 400 locations across the region. Frustrated with The Joint Commission, Midland Memorial Hospital (TX) made the shift to DNV this year, says accreditation specialist Lisa Williams, PT, MS, HACP.The hospital had already been looking at the Centers for Medicare & Medicaid Services' conditions of participation in 131 0 obj Why? 0000009113 00000 n The purpose of the initial visit is twofold: Based on this, the scope and audit plan are agreed upon. Findings, including non-conformities, and conclusions are presented at the end of the audit in a closing meeting and included in the audit report. `0 d``_}C!\ |S0\`0[znV$5*c"00z`PwzS\u@_w{wSZ3@`|4iE"'-*5wIsr]gI qyO'WAm)U1Ys96S=ffXTjMJ5P)TTOVyN9xddiV,ey-E% The decision to grant initial certification, renew certification or to expand or reduce the scope of certification, is made by competent and authorized personnel in DNV who are different from those carrying out the audit. Project Director, CHC Accreditation . DNV is kept apprised of the organization's level of compliance with ongoing organizational reporting. N')].uJr %%EOF What happens if an organisation fails to maintain their management system and certification? Therefore, accredited certification consists of a 3-step cycle: To tailor the audit, we need to know what is important to your organisation. V)gB0iW8#8w8_QQj@&A)/g>'K t;\ $FZUn(4T%)0C&Zi8bxEB;PAom?W= SCRMC has three years from the date of its accreditation to achieve compliance with ISO 9001, the worlds most trusted quality management system used by performance-driven organizations around the world to advance their quality and sustainability objectives. AORN statement on nurse-to-patient ratios. Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. AORN Guidance Statement: Perioperative Staffing. Academic & Personal: 24 hour online access, Corporate R&D Professionals: 24 hour online access, https://doi.org/10.1016/j.mnl.2009.10.004, Comparisons of the NIAHO and Joint Commission Approaches to Accreditation, Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf, Available at: http://www.dnv.com/binaries/NIAHO%20Accreditation%20Requirements-Rev%20307-8%200(2)_tcm4-347543.pdf, Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf, For academic or personal research use, select 'Academic and Personal', For corporate R&D use, select 'Corporate R&D Professionals', Association for periOperative Registered Nurses. All rights reserved. Four years on, upstart nears 350 clients. WebThis approval provides hospitals with another accreditation option in addition to the Joint Commission and the American Osteopathic Association. HlSn0}W*vHUYii& 3kj`{YiDsqHI)P(J|\*|H X(PnFc'G]=/L$)$M[x6i; `9aDv}~2$eY@5 f'N^O_SFda55,EgsHwJWP'* xi.qDU_4%4reA)4zq0l>vf_R3;hxxlqn=hK`I8BL!eAS$O=pJI`2xKtQ_hv6 bG2u.S?)UIraqn/S#5gCi3+D WmBK%# DNV Healthcares hospital accreditation program is unique in that it integrates the ISO 9001 standards (international quality standards that define Access our full portfolio of public and private courses, including CHOP Certification. endstream endobj 155 0 obj <>/Size 127/Type/XRef>>stream hYmo6+bwRPI-@fulAMTcg5~w'I :^xXoay-uL3,%a8J#!%@aY%I>)ddJ:ph+*jX 9Q43F:\RzvYV:ibv2gTM]oWjQ)|V?AtYuy[uq]{ About 200 hospitals have switched to DNV Accreditation over the past two years. endstream endobj 1328 0 obj <>/Metadata 142 0 R/OCProperties<>/OCGs[1339 0 R 1340 0 R 1341 0 R]>>/Outlines 204 0 R/Pages 1318 0 R/StructTreeRoot 287 0 R/Type/Catalog>> endobj 1329 0 obj <>/ExtGState<>/Font<>/Properties<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1330 0 obj <>stream South Central Regional Medical Center was the first hospital in Mississippi to be accredited by DNV Healthcare. 2023 Rochester Regional Health. 2y.-;!KZ ^i"L0- @8(r;q7Ly&Qq4j|9 Compliance is viewed as a 3-year The Joint Commission on the Accreditation of Healthcare Organizations. We have to get a clear understanding of your business strategy and conditions that affect your ability to reach said strategy. 0000038975 00000 n 0000012451 00000 n 1350 0 obj <>stream SOUTH CENTRAL REGIONAL MEDICAL CENTER RECEIVES QUALITY-BASED ACCREDITATION FROM DNV. Medical Student SOAP Note | At this stage you have completed the initial certification and can move on to maintenance of your certification. Joint Commission Online, August 12, 2009. An integrated health services organization serving the people of Western New York. You will then receive an email that contains a secure link for resetting your password, If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password. I*Rt>[?Yim*>"1t>hvYJa`h0vh` 2+@,F0)fP`c6e,ITWhLVJCXLFu @B@h6{E@E"% @lT- g Hu.5LL00~gPdpMej8 PClY~p=Tt n`xH108Y * ~ D\z 23, Sections 1-6 1-7 commission and graduated commission, What are the defects of existing curriculum, Joint commission oxygen cylinder storage 2019, DNV Managing Risk DNV corporate presentation Elzbieta BitnerGregersen, JOINT COMMISSION PANEL DISCUSSION REGARDING RECENT JOINT COMMISSION, COMPARISON AND CONTRAST COMPARISON CONTRAST Comparison points out, Aligning Accreditation and Quality The DNV Perspective The, Introduction to IDSADI 15926 Resources Ian Glendinning DNV, DNV Healthcare Top Survey Findings Medical Staff National, SOLAS requirements DNV interpretations Jan Tore Grimsrud February, Mobile Technology in Ships Inspections Thomas Mestl DNV, RBI Intro some activities at DNV Fatigue Workshop, INTRODUCING INTUMAXEP 1115 XHP DNV CERTIFICATE NO F16685, CBCD Cloned Buggy Code Detector Jingyue Li DNV, DNV a Norwegian company in Korea with focus, DNV GL studie LNG in de scheepvaart verlagen, KNEE JOINT ANKLE JOINT HIP JOINT Prof Ahmed, Shoulder Joint Shoulder Glenohumeral Joint The shoulder joint, Elbow Joint Elbow Joint Type Synovial hinge joint, SYNOVIAL JOINT Dr Iram Tassaduq SYNOVIAL JOINT Joint. endstream endobj 128 0 obj <>/Metadata 20 0 R/PieceInfo<>>>/Pages 19 0 R/PageLayout/OneColumn/StructTreeRoot 22 0 R/Type/Catalog/LastModified(D:20081002145347)/PageLabels 17 0 R>> endobj 129 0 obj <>/ColorSpace<>/Font<>/ProcSet[/PDF/Text/ImageC/ImageI]/ExtGState<>>>/Type/Page>> endobj 130 0 obj <> endobj 131 0 obj <> endobj 132 0 obj <> endobj 133 0 obj [/Indexed 148 0 R 255 149 0 R] endobj 134 0 obj <> endobj 135 0 obj <> endobj 136 0 obj <> endobj 137 0 obj <>stream <>/XObject<>/ExtGState<>/ProcSet[/PDF/Text/ImageC]/Font<>>>/MediaBox[ 0 0 612 792]/Contents 168 0 R /Parent 117 0 R /Type/Page/CropBox[ 0 0 612 792]/Rotate 0/Annots 145 0 R /Tabs/S/Group 166 0 R >> n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. 0000002975 00000 n Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf. We are honored to provide behavioral healthcare facilities the same option provided to their hospital partners - a choice in their accreditation.PsychiatricHospital Accreditation Program Components Select from the topics below to get started. The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. nQt}MA0alSx k&^>0|>_',G! {(oFA`=My$RqH+#~/aDh4:G}_.Q8f(fVJ7*7/oG|t6FG\kpvaGx2?yxz RlG@-e0&9zWez|U( v DNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. Webknown as DNV Accreditation, they came equipped with the experience of TUVs previous effort to become deemed and their National Integrated Accreditation for Healthcare 0000006807 00000 n endstream endobj 1332 0 obj <>stream 0000002012 00000 n WebThe organizations are surveyed annually. anDkDMMmnZWh|rQl( Accessed April 23, 2010. Det Norske Veritas (DNV) is a global quality Each issued certificate has a three-year life period. DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. 1327 0 obj <> endobj %%EOF Upon certification, we will create a periodic audit schedule for regular audits over the three-year period. 0000009720 00000 n hbbd``b` @)H0A@"*HpE$> oL,F6~0 d Comparison of The Joint Commission and DNV- GL HCs National Integrated Accreditation for Healthcare Organizations (NIAHO) MS Standards Kathy Matzka, CPMSM, CPCS 1, History TJC 1952 began Unique statutory hospital deeming authority 1965 Medicare statute July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 became law 11/09 CMS approval 4, 546 Hospital and CAH in 2011 4, 429 Hospital and CAH in 2013 (90% of accredited hospitals) 4, 032 Hospital and CAH in 2016 (88% of accredited hospitals) NIAHO 12/19/07 Application to CMS 09/08 CMS approval 94 Hospital and CAH on 7/14/10 393 Hospital and CAH on 4/17/2016 2, Process TJC NIAHO Three year survey Annual Survey Standards directly Most MS standards related to the CMS as directly related to the well as self-defined CMS ISO 9001 quality management 3, Scoring Process TJC NIAHO Three-point scale: 0 = insufficient compliance 1 = partial compliance 2 = satisfactory compliance Icons Documentation required Situational decision rules apply Direct impact requirements apply Category A requirement Category C requirement (based on # of times does not meet standard) Measurement of Success needed Standards Scored as Meets requirements Nonconformity Category I Conditional level Egregious non-compliance Nonconformity Category I Noncompliant Nonconformity Category II Occasional or isolated lapse in compliance Immediate Jeopardy Immediate threat to patient safety No aggregate scoring 4, Appointment Timeframe TJC Two years NIAHO Three years if state law does not address 5, Continuing Medical Education TJC NIAHO LIPs and other practitioners All with privileges participate in privileged through the medical CE that is at least in part staff process must participate related to their clinical in CE privileges Participation must be CME considered in decisions documented and considered in about reappointment or decisions about reappointment, renewal or revision of clinical renewal, or revision of privileges individual clinical privileges Action on an individuals application for appointment /reappointment or initial or subsequent clinical privileges is withheld until the information is available and verified 6, Current Competence TJC The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence Evaluate data from other organizations where the applicant currently has privileges, if available NIAHO Initial - MS qualifications include verification of current competence Reap - Review of individual performance data for variation from benchmark Variations to peer review for determination of validity, written explanation of findings and, if appropriate, an action plan to include improvement strategies 7, Malpractice History TJC NIAHO MS evaluates Review of involvement in a any professional liability action at initial and action, including final reappointment judgments and settlements involving a practitioner Must evaluate any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant 8, Peer Recommendations TJC NIAHO Required at initial, reap, consideration of termination, or revision/revocation of clinical privileges Address the relevant training and experience, current competence, and any effects of health status on privileges being requested Include evaluation of the applicants medical knowledge, technical and clinical skills, clinical judgment, communication skills, interpersonal skills, and professionalism Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicants ability to practice List of appropriate sources Two peer recommendations required at initial appointment 9, Clinical Privileges TJC NIAHO PSV for current licensure or All permitted by the certification organization and by law to PSV of relevant training provide patient care services Evidence of physical ability to independently have delineated perform the requested privilege clinical privileges If available, data from If available and/or required by professional practice review the MS, a review of individual from other organization where performance data variation the applicant currently has from criteria determined by the privileges medical staff to identify need Recommendations from for training or proctoring that peers/faculty may be required On renewal, review of the applicants performance within the hospital 10, Telemedicine TJC NIAHO 3 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing information from the distant site if the distant site is a Joint Commission-accredited organization or Use credentialing and privileging decision from the Joint Commission-accredited distant site Medical staff at both sites make recommendation for services to be provided via telemedicine For non-deeming, can be via contract only if TJC accredited entity 2 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing and privileging decision from telemedicine entity or distant site Medicare participating hospital When services provided by a contracted entity, GB must identify criteria for selection and procurement of services and how to evaluate the entity 11, Temporary Privileges TJC NIAHO 120 days for new applicant with complete file awaiting MEC approval Time as specified in bylaws for patient care need On recommendation of MS President or designee No successful challenges to licensure or registration; involuntary termination of MS appointment; involuntary limitation, reduction, denial, or loss of clinical privileges Not exceed 120 days Locum tenens not to exceed 6 months On recommendation of a MEC member, MS president or medical director (as defined by MS Urgent patient care need Complete application w/o negative or adverse information before action by the medical staff or governing body 12, Temporary Privileges TJC NIAHO Patient care need verify Current licensure Current competence New Applicant verify Current licensure Relevant training or experience Current competence Ability to perform the privileges requested Other criteria required by medical staff bylaws NPDB In all cases verify education (AMA/AOA Profile OK current competence primary verification of State professional licenses professional references (including current competence) Database profiles from AMA, AOA, NPDB, and OIG Medicare/Medicaid Exclusions 13, Allied Health Professionals TJC NIAHO LIPs through MS process Non-LIP APRNs and PAs HR or MS if not providing a medical level of care If State law allows, MS may include DPM, OD, DC, PA, CRNA, NM, APRN, DMD, PHD or other designated professionals approved by MS and Board and eligible for appointment 14, Executive Committee TJC NIAHO 10 EPs outlining responsibilities, structure, function If MS has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy CEO and the nurse executive of the organization or designee shall attend each meeting on an ex-officio basis, with or without vote 15, TJC Notifications NIAHO The decision to grant, A current roster listing deny, revise, or each practitioners revoke privilege(s) is specific surgical disseminated and privileges must be made available to all available in the appropriate internal surgical suite and external persons scheduling area or entities, as defined Include surgeons with by the hospital and suspended surgical applicable law privileges or whose surgical privileges have been restricted 16, Surgical Privileges TJC NIAHO Included in general category for privileges All practitioners performing surgery have surgical privileges established by the department of surgery and medical staff and approved by the governing body Privileges for general surgery and surgical subspecialties defined with established criteria approved by MS Privileges correspond with established competencies of each practitioner 17, Automatic Suspension TJC NIAHO The medical staff bylaws include description of indications for automatic suspension or summary suspension of a practitioners medical staff membership or clinical privileges description of when automatic suspension or summary suspension procedures are implemented The medical staff will define the criteria and have a mechanism for consideration of automatic suspension of clinical privileges of a practitioner at a minimum when: revocation/restriction of professional license DEA certificate has been revoked, suspended or on probation Failure to maintain the minimum specified amount of professional liability insurance non-compliance with written medical record delinquency or deficiency requirements Mechanism for immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioners Medicare or Medicaid status 18, QA/PI Data TJC FPPE OPPE Medical Assessment Blood Medication Operative and other procedure(s) Appropriateness of clinical practice patterns Significant departures from established patterns of clinical practice Use of criteria for autopsies Sentinel event data Patient safety data NIAHO Practitioner specific performance data is required and must be ratebased with comparative peer or national data available for comparison.