What to expect from a DNV Healthcare survey

Focus on outcomes, document control, CoPs

In preparation for its unannounced survey with DNV Healthcare, Citizens Medical Center personnel readied their survey preparation box. Last minute documents were pulled when surveyors arrived for the unannounced survey — a patient census, the surgery schedule, a list of patients in restraints.

"Kind of the same things you would pull for The Joint Commission," says Caren Adamson, assistant administrator for the Victoria, TX-based hospital.

Then they assembled a team to accompany the surveyors — including Adamson, director of quality Cherie Brzozowski, the director of engineering, the assistant administrator for nursing, hospital educators — with whom they shared the survey schedule.

DNV's accreditation program, NIAHO, hinges on Medicare's conditions of participation (CoPs) and the ISO 9001 methodology. The process secures participation in the Medicare/Medicaid program and signals an introduction to working within ISO and optional certification. But prior knowledge of the ISO system is not required to go through the NIAHO process, says Patrick Horine, executive vice president of accreditation for DNV.

Horine says when DNV surveyors arrive, they will deliver the schedule outlining the documents for review. "Then we just start laying out the meetings for the survey activity. So first activities would involve things like the quality management review, starting to look at patient units," he says.

Initial interviews would usually include infection control, medical staff, HR, and offsite clinics, with a primary survey team comprising a generalist, someone with an administrative or quality-related background; a clinician, either a nurse or physician; and a physical environment life safety specialist.

Adamson says in many ways the survey was similar to the tracer methodology used by The Joint Commission. With the hospitals' policies in hand, surveyors "looked for evidence that we were practicing what we said we were going to do. They followed that pretty closely," she says.

"They focused on all the standards within the conditions of participation, and they followed that to a tee. They evaluated our compliance with those standards. They visited all of our patient care units. They visited with our staff. They looked at open records; they looked at closed records. They were very thorough," Brzozowski says.

Process, document control

The difference in working with DNV, according to Brzozowski, was the emphasis on processes — how they are followed and how they affect outcomes. She suggests that hospitals going through the NIAHO program "focus on outcomes, looking at the end results of your efforts and how that had an impact on patient safety and quality."

"We don't have patient safety goals," says Horine. "We're very focused on hospitals being innovative, identifying best practices." Prescriptive, cookie-cutter approaches don't allow for the differences between, for instance, a 25-30 bed hospital and a Cleveland Clinic, he says. "You need to be cognizant of that when you're surveying. There can be effective ways of doing things without us prescribing every aspect of it."

A big challenge for Brzozowski and Adamson in preparing for their survey was document management. "With ISO, under this document control, we were challenged to find a process that allows us to present to our employees the most recent form, the most recent policy so they don't get confused in the work we're asking them to do," says Adamson.

Horine says surveyors are finding that hospitals, for instance, might have three different ways of obtaining informed consent or multiple versions of a procedure in place. He recommends hospitals look at how they handle forms and documents. "Documentation completeness seems to be a problem," he says, such as deficiencies in updating care plans or the processes for authenticating orders.

"What we're doing is after the initial survey, we're looking for hospitals to streamline some of that."

Focus on CoPs

In working with DNV, Adamson recommends "focusing on the CoPs where it states a policy is required." Seems simple enough, but Horine says in working with hospitals, DNV has seen that many have "gotten away from knowing the conditions of participation. Although they still remain accountable for those, they look at their one source for accreditation and lose sight of the CoPs. So it's kind of getting hospitals back to the basics.

"The focus right now is on the National Patient Safety Goals, and they lose sight of some of the important aspects of the hospital just so they can focus on those. But I think that hurts in many ways, looking at the overall scheme of things in patient care."

He says CMS recently updated the state operations manual, which hospitals need to be familiar with. Two areas he says DNV sees hospitals struggling with on CoPs: the time frames and requirements on patient grievances and how to respond to those and updating H&Ps prior to surgical procedures.

(Editor's note: You can download NIAHO requirements at http://www.dnv.com/focus/hospital_accreditation/.)