What makes a hospital change accreditors?

Two facilities outline their rationale

At the 100-bed Morehead Memorial Hospital in Eden, NC, the journey from TJC to DNV took two years, says Susan Netherland, RN, MBA, director of quality management and compliance officer at the facility (for a description of that two-year journey, see story, below). "We were TJC-accredited for years, but we had concerns after our last survey," she explains. "There were many small picky things, and so many standards and so many elements of performance, that it was hard to meet them all. And it was all subjective to the surveyor. We had one surveyor tell us something was a great idea, and another that it wasn't. It wasn't the outcome that seemed to interest them, but how we got there. We thought that was wrong and our medical staff were increasingly unhappy. They wanted the big picture of quality to be the most important thing to the accreditation body."

The thing that first got the Morehead Memorial administration interested in the DNV process was its focus on the CMS Conditions of Participation (CoPs), rather than a separate set of standards. "We all know them, and we all have to abide by them," Netherland says. The CoPs come with interpretive guidelines, she notes, while if you have six different Joint Commission surveyors and a single standard, you may get six different interpretations of it.

Netherland likes that DNV also bases its accreditation on ISO 9001, which is an internationally recognized management system that impacts every part of an organization — from housekeeping to neurosurgery, every employee from porter to chief executive. DNV gives a facility three years to reach ISO 9001 status, and returns annually to check on progress. "That's an excellent quality structure," she says.

Netherland says she was impressed with how focused the organization was on outcomes during the survey, which occurred during three days in July. If you choose to mark the right surgical site with a balloon bouquet attached to the appropriate body part rather than with a felt-tipped marker, that's fine, she notes. That there are no wrong-site surgeries is the important thing.

Before making the final decision, Netherland says they had to check with all payers and bond companies to make sure they would accept the DNV accreditation. The lab at the hospital, which was also TJC-accredited, was another issue. You can't maintain TJC lab accreditation if the hospital itself isn't using TJC. So, Morehead Memorial transitioned to the College of American Pathologist (CAP) accreditation.

After letting TJC know it was dropping from its program, the organization conducted an exit interview, Netherland notes. When she had her exit interview with TJC, Netherland says she was blunt with the organization about the reasons they were changing, the strong desire from the medical staff, and the problems they had with previous surveys and surveyors.

Among the stories she shared: an instance when a second survey was required for findings related to paperwork that could have been forwarded by email. Instead, they paid $6,000 for what amounted to a one-hour visit by a nurse so old that had she been required to do any climbing to look for something, she wouldn't have been able to, Netherland notes. Another issue: They didn't get the final accreditation certificate from a 2010 survey until this last spring. Why? There was torn furniture and they were required to monitor it for 18 months. "Nitpicky things like that drove us away."

All of the 1,000 employees at the hospital received training on the new accreditation program. "We explained the switch, why we were making it, and what DNV would be looking for."

The survey itself wasn't largely different — DNV uses tracers, like TJC. Netherland says that they seem to be very policy-driven and will ding you if you have a policy that specifies a specific action and you can't prove it was done.

"No one ran away from these surveyors," she says. "They were relaxed with us and answered our questions. I even wondered if they weren't doing a good job because I wasn't in a panic."

DNV looks for patterns of problems, she says, rather than single incidents. For example, there was an open carton of milk in a nutrition refrigerator. But it was just one carton of milk in one refrigerator, and the hospital wasn't cited for that, but educated on the finding. Surveyors didn't just mention issues to address, Netherland continues. "They also told us about the 'wow!' moments where they found something outstanding. On the last day, one surveyor told us she would be happy to be a patient here."

The findings are structured into Non-Conformity 1 and Non-Conformity 2 findings, as well as findings that are related to the immediate threat to patient safety. They had none of the latter. Non-Conformity 1 findings need to have a quick fix — with an action plan returned to DNV within 10 calendar days and send measurement of success within three months. Non-Conformity 2 problems are checked at the next annual visit.

In the former category, Morehead needed to get a separate permit for anesthesia services, and improve temperature monitoring of refrigerators. Most of the Non-Conformity 2 issues related to data missing from physician reports.

In a year, at least one person from the original survey team of four will return for the next survey. Netherland says that continuity is another plus to her.

TJC isn't completely absent from the Morehead world, Netherland says. The hospital will continue to use some of the organization's standards, like using two patient identifiers. And it will keep up with the sentinel event alerts issued by the commission. DNV doesn't yet have the extensive website and tools available that TJC does. But they are quick to answer questions through the online "drop box" program. Listservs for other organizations will stand in for TJC collaboratives when it comes to searching for solutions to common problems.

The cost isn't a whole lot different, she says. "The surveys are a little more expensive, but there isn't an annual fee and you don't have to buy all the standard books. I think it's a break-even situation, or maybe a little cheaper with DNV over the three-year accreditation period."

As the facility moves forward with ISO certification and continued accreditation from DNV, Netherland says she continues to get questions from peers about their experience. And she's happy to sing DNV's praises. "We are just the fourth hospital in North Carolina to go with them," she says. "People are interested in what we did, but still skittish. They worry that patients will care about the change. The Joint Commission has done a great job marketing itself, but patients care that you are accredited, not who does it."

She says Morehead will continue to evaluate accreditors and the accreditation process, but she would be surprised if they went back to TJC. "This was the most amazing survey process I've been involved with in the 44 years I've been a nurse."

Positive experience from both

Good Samaritan Hospital in Downers Grove, IL, changed from TJC to DNV in April. It is one of 10 hospitals in the Advocate Healthcare System that is changing, and was in the group of three that went first, says Marty Dietrich, MPH, RHIA, CPHQ, director of quality improvement and regulatory affairs for the hospital.

She was on the steering committee that made the decision to change. For them, there was no issue with The Joint Commission, but rather a determination to be ISO 9001 certified. "The Joint Commission had talked about moving that way, but there were no great plans as to when," she says. "As a Baldrige organization, we are very process-driven, and you can line up Baldrige and ISO criteria next to each other and they match up very well."

The ISO 9001 platform improves service consistency and operational efficiency, says Dietrich. "It increases patient satisfaction scores and enhances customer perception — a lot of them have heard of ISO through jobs in manufacturing or other industries. We think it gives us a competitive advantage and an internationally recognized designation that gives us access to a wider quality form."

The Joint Commission used Good Samaritan as a training site for international surveyors, and Dietrich says they had — and continue to have — a great relationship with the organization. But they wanted to stick with the CoPs as basic standards and add the ISO 9001 certification.

When she went through the first survey with DNV, she says she was surprised at how informal and low-key it was. "With TJC you have a formal presentation on the first day, but DNV wasn't interested in that. We had provided them with a lot of information ahead of time, and they were quite familiar with us. They knew about our quality plan — there was a closed-door evaluation of it — and our scope of service for every single unit and department in the hospital. They used the tracer methodology like The Joint Commission, but I think they are more interactive with the staff."

There are more findings, and while TJC requires that you be in the 90th percentile and have 90 days to fix problems, DNV is focused on improvement, Dietrich notes. "If half of your records aren't complete, they won't expect you to reach 90% within 90 days. Unless it is a condition-related finding, they are happy to see that you are making progress within three months, and they'll check again when they resurvey you in a year," Dietrich says.

The findings at Good Samaritan were not much different from those that TJC found the last time they were there, she says. "Level two findings like documentation issues — signing and dating of things."

DNV surveyors lead the survey more, and Dietrich says she felt less in control, but that was fine. "They knew where they wanted to look when they came in. They asked for a list of contracted services. They looked for patterns. They dug deeper if they saw something that troubled them." One thing that she likes about the DNV process is that it emphasizes to the organization as a whole that quality isn't just the property of a single department. Rather, it is everyone's responsibility.

Dietrich says the surveyors were knowledgeable about healthcare, having worked in the industry recently, and for years. "They understood the constraints and responsibilities," she notes. "They were interested in bringing things to our attention and helping us find ways to solve problems."

The informality threw some people at Good Samaritan for a loop initially. "They wondered if their being so relaxed somehow meant there would be some serious dings," she recalls.

The findings went to the regulatory committee, which has key leaders from a multitude of departments and disciplines. They suggested fixes and ways to improve. Now there are continual mock surveys and no sense of having to rush to get ready for what's coming next spring.

There are things that she wishes were different, like a more robust and interactive DNV website, perhaps a way to communicate with other clients about problems and how to solve them.

DNV president Yehuda Dror notes that there is a symposium coming up that will have some 250 participants and will include a presentation from a hospital on how to prepare for and achieve ISO 9001 certification.

Five more Advocate Healthcare hospitals are due to be surveyed before the end of the year, with the remainder getting their turn under the microscope in the early part of 2013. With TJC testing ISO 9001 certification programs, Dietrich says Advocate will likely re-evaluate certification options in the future. "The door is never shut for them," she says. "We will continue to look at what they are doing."

Meanwhile, TJC's national patient safety goals will continue to be part of Advocate's quality improvement and patient safety program. "They are excellent, and we think even though DNV isn't looking at them, we see value in continuing." Other Joint Commission programs will also stay on Dietrich's radar.

In the next issue, Hospital Peer Review will look at some hospitals that evaluated DNV and opted to stay with The Joint Commission for why they consider TJC a better option for them.

For more information, contact:

  • Yehuda Dror, President, DNV Healthcare, Milford, OH. Email: yehuda.dror@dnv.com.
  • Ann Scott Blouin, RN, Ph.D., FACHE, Executive Vice President, Customer Relations, The Joint Commission, Oakbrook Terrace, IL. Email: ablouin@jointcommission.org.
  • Susan Netherland, RN, BSN, MBA, Director of Quality Management/Compliance Officer, Morehead Memorial Hospital. Eden, NC. Telephone: (336) 623-9711x2364. Email: snetherland@morehead.org.
  • Marty Dietrich, MPH, RHIA, CPHQ, Director, Quality Improvement and Regulatory, Advocate Health, Downers Grove, IL. Telephone: (630) 275-1477. Email: marty.dietrich@advocatehealth.com.

What's taking so long?

One hospital's two-year trek from TJC to DNV

Two years sounds like a long time to move from one service provider to another, but it wasn't dawdling that stretched the time for Eden, NC-based Morehead Memorial Hospital to shift its accreditation surveys from The Joint Commission (TJC) to DNV, says Susan Netherland, RN, MBA, director of quality management and compliance officer.

After getting complaints from medical staff, the executive management team investigated the alternatives and decided to look in depth at DNV, scheduling a conference call between the board, medical leadership, and DNV executives. That was followed by Netherland reaching out to several DNV client hospitals for references and investigating any cost differential between TJC and DNV.

Netherland and her team checked with insurers and financial institutions to ensure a change was acceptable to them, as well as with the Commission on Cancer, which accredits the Morehead cancer center. DNV then did a site visit.

"The thing that took the longest was trying to ensure we could make the transition between Joint Commission visits," she says. "We also had to transition the lab to be certified by the College of American Pathologists (CAP), which required about a year of preparation." The last TJC survey was February 2010, and TJC was due again in early 2013.

Before then, she needed to educate staff on the change, ramp up understanding of the Conditions of Participation on which DNV bases accreditation, and also start learning about ISO 9001. "Another issue that made our transition a little longer was that we had a fairly large turnover in nursing leadership and some things could not move forward until that structure was back in place."