Accreditation Field Report

Midland Memorial happy with DNV shift

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 order to keep up with Joint Commission standards that were coming in line with those. So Williams says there was no real preparation. She told the leadership team: "There's nothing we can do to prepare. We really should be ready all the time instead of trying to get a bunch of stuff done [right before the survey]. Whatever they find, we'll fix."

She says she attended several presentations on DNV and what she heard was "refreshing in that their standards are based on CMS conditions of participation, which as we all know don't change very much. And then those conditions of participation are integrated with the ISO 9001 quality management system."

What drew her in was DNV's revelation that "you know your organization best, and you decide what's important to your organization. If you don't have trouble with X, Y, and Z, then you don't have to worry about them, but you should be studying them and know that you don't have trouble with X, Y, and Z."

Williams says that was a different take than The Joint Commission's. She points to the disruptive behavior standards. Leadership had spent more than a year defining disruptive behavior and what they were going to do about it. But, she says, "We don't have those problems here... We dealt with our disruptive people effectively. But we had to put all these things in place and jump through all these hoops because somebody else had a problem somewhere else in the health care world."

DNV, she says, is collaborative and "like an auditor that's going to come in and see that we're doing what we're supposed to be doing, what we say we're going to do as opposed to 'Are you doing what we're telling you to do?'"

She says she was almost floored when DNV came for its first survey in October and didn't get to every area and said, "What I don't see this year, I'll see next year. It's OK." DNV has annual surveys vs. The Joint Commission's triennial survey.

DNV also is "very good at sharing from one hospital to another. 'This is what works well for us here....' That's the difference with ISO is that there's a product on the end. There is a certain product that is being delivered and that's health care. And we want to deliver the best health care." She sees The Joint Commission's motive as fundamentally different. "With The Joint Commission, it becomes more about the process in the middle and how you're doing steps A, B, C, and D, as opposed to what happened at the end."

For the survey, four surveyors came for three days — one life safety surveyor who stayed throughout the survey, a clinical nurse surveyor, a generalist surveyor, and a team leader with a pharmacist background. Midland Memorial was praised for its work on HR competencies. Williams says everyone in the organization is required to have a competency and it's "done a very comprehensive review of employee job descriptions and what we consider to be competencies."

It also was praised for its infection control processes in cleaning equipment in areas such as endoscopy and the operating room. The surveyors did find some loose infection control processes in terms of consistent application of isolation precautions, she says.

Although the CMS CoPs don't touch on FPPE or OPPE, that is a policy Midland will continue to work on. But they are sifting through other Joint Commission requirements and deciding which ones they should continue working on. For example, reporting critical values was never a problem, but William says she used "to spend the better part of her day doing an audit of those critical values. And we've decided as an organization that we're not going to do that anymore because we've not had any issues."

Midland did get cited for updating H&Ps. "We were cited for lack of timely updates. Part of our corrective action plan, which is working, is that the circulating nurse checks for an update prior to the patient being taken back to the operating room and no patient is taken back without either a current H&P or an updated H&P.

"Prior to our survey, there was not a check for an update, and the only thing looked at for H&Ps was if there was one there, not when it was performed. All circulating staff were educated, and all surgeons were also educated. We have been doing random audits of usually first cases of each room each day and have improved our compliance from a baseline of about 10% to 87% at our last weekly check. Our feedback to physicians is to fax them a letter indicating where they failed to update the H&P timely. Unfortunately, this feedback has not been very timely, but we are in the midst of implementing a compliance manager software tool that will greatly improve the efficiency of communication from the data collectors to me, who is responsible for faxing letters to physicians," she says.

DNV also found that light switches in the med gas storage room had not been installed with the proper specifications. Had a Joint Commission surveyor found the same thing, Williams says, the hospital would have relocated the switches, sent that information to Joint Commission, and been fine. But with DNV when a hospital turns in a corrective action plan, it must do a root-cause analysis of why it happened and all areas that could be affected by that. "So we had to look at how we were managing our construction and look at other med gas storage rooms in our organization. Just doing that root-cause analysis opened up a whole area of construction management," she says.

Since its survey, Midland has been looking at its grievance process and managing that in one area. Before, if a patient for example complained to the quality management department, it was logged. But if a person made a complaint with the radiology department, that department would handle it and no one else was aware of it.

DNV also focused heavily on restraints and the hospital's care plan.

Williams says The Joint Commission "wants you to have everything fixed when you turn in your information. What DNV asks is that you turn in either what you fixed and what you plan to continue to fix because things just can't done in 60 days." DNV, she says, is not solely concerned with processes but outcomes as well, and you can't look at that unless you have data. She says the board has been happy with the switch. "Our board understands ISO. The don't really understand The Joint Commission." But, she says, they won't cut Joint Commission out of the picture altogether. For those things the hospital identifies as necessary, they will keep.