Following a positive decision you will receive the certificate shortly thereafter. Infection Control & Hospital Epidemiology. 0000006234 00000 n WebAccreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. An integrated health services organization serving the people of Western New York. CMS-2895-FN, September, 26, 2008. The Joint Commissions Stroke Certification Enhancements for 2018. 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 "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 Our lead auditor will verify that you have properly addressed the nonconformities. David Eickemeyer, MBA; Associate Director, Hospital Business Development. Deemed Status DEPARTMENT OF HEALTH & HUMAN SERVICES endstream endobj 138 0 obj <>stream Upon certification, we will create a periodic audit schedule for regular audits over the three-year period. Making the Switch: Washington Hospital Turns to DNV DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. The Joint Commission on the Accreditation of Healthcare Organizations. Below are several components of our psychiatric hospital accreditation program. The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. Web DNV GL Healthcare (DNV GL) The Compliance Team (TCT) The Joint Commission (JC) There are currently another seven AOs approved under CLIA, which are: American Association of Blood Banks (AABB) American Association for Laboratory Accreditation (A2LA) American Osteopathic Association (AOA) DNV: Det Norske Veritas: DNV: Der Norske Veritas: DNV: District of North Vancouver (British WebThe organizations are surveyed annually. endstream endobj 139 0 obj <>stream 156 0 obj <>stream 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. startxref WebThe JCAHO and its accreditation programs are described, the history of the Medicare-JCAHO relationship is reviewed, and why the federal Medicare program has relied on accreditation as an indicator of the quality of participating hospitals is examined. Accessed April 27, 2010. Accessed August 5, 2009. Download the Standards created and offered by DNV Healthcare, Project Director, CHC Accreditation . Find out more about our accreditation, certification & training programs. 0000003710 00000 n <>/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 >> org 22, Questions to Consider Will our reputation in the community suffer if we change? South Central Regional Medical Center was the first hospital in Mississippi to be accredited by DNV Healthcare. The purpose of the initial visit is twofold: Based on this, the scope and audit plan are agreed upon. The report indicates if your organisation is ready to proceed with the certification audit. 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 $200 million. Admin, South Central Family Medicine & Urgent Care, Directions to South Central Regional Medical Center, Where to Get the Best Care and When to Go. hYmo6+bwRPI-@fulAMTcg5~w'I :^xXoay-uL3,%a8J#!%@aY%I>)ddJ:ph+*jX 9Q43F:\RzvYV:ibv2gTM]oWjQ)|V?AtYuy[uq]{ WebDNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. H|S[o0~WL3CJ)d[+ej8["ChT(/>| Lr= 1A/?7_]"`WW0 MB%pf4{R)"~"LeC$X8 V+I::'p8%I^H$pfr>8hY6/Fd&JA#aNj,'{?li1z\) This helps hospitals create a corrective action plan to improve their process and prevent that variance from occurring again. DNV is kept apprised of the organization's level of compliance with ongoing organizational reporting. (Are minimal standards sufficient in todays healthcare climate? ) In recent years, DNV have been challenging TJC in the USA. 121 0 obj *This product is a downloadable document and does not ship. endstream endobj 1332 0 obj <>stream This process ensures a full and timely understanding of the standards. Learn About Accreditation Survey We evaluate how well your management system supports your focus areas. Accredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. Digital monitoring of medium-voltage cable networks, Offshore classification fleet in service, Electric grid performance and reliability, Reliability, availability and maintainability (RAM), Ship management, operations and ship design, procedure for suspension and withdrawal of certificates. Published by Elsevier Inc. All rights reserved. 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. Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. Risk Based Certification is our exclusive approach to all management system certification. hTkSI?ssMl Public Records Policy | 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. At Rochester Regional Health, our dedication to quality is reflected in the teams we hire, the care we provide and the services we offer. NIAHO is the National Integrated Accreditation for Healthcare Organizations and encourages collaboration between different hospital departments. 0000012451 00000 n By 1991, TJC had learned that it was not possible to ensure quality and had moved on to quality improvement and its many iterations, now known as performance improvement. DNVs accreditation program is the only one to integrate the ISO 9001 Quality Management System with the Medicare Conditions of Participation. As DNV hospitals often say, ISO provides the structure for the staff to focus on 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. Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. 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 ISO is the International Organization for Standardization. Using an accredited third party certification body/registrars Compliance is viewed as a 3-year Because while undergoing the accreditation process, a hospital makes critical decisions about how it provides services, manages medications and allocates resources. 2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. The documentation review report summarizes any findings from this process. 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. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. To review focus area input and agree on one to three particular focus areas upon which the audit will focus. The certification decision is taken after an independent DNV GL internal review. 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.