Understanding DNV as an accreditation option
In 2008, Det Norske Veritas Healthcare, Inc. received notification that it had been approved by the CMS to deem hospitals in compliance with the CMS Conditions of Participation for hospitals. The survey application process took more than four years to complete, and DNVHC was the first company in over 40 years to submit an application and subsequently have it approved. DNV, which means "the Norwegian truth," originated in Norway in 1864 as a risk management company. Their mission is dedicated to safeguarding life, property and the environment.
Believing that the current accreditation programs in the United States had little impact on business practices that are responsible for creating quality and controlling costs, DNVHC was formed and proposed an accreditation model that focused on "improvement" and "sustainability" rather than "survival." Its approach to accreditation utilizes the National Integrated Accreditation for Healthcare Organizations requirements.
At the time of publication, approximately 370 acute-care hospitals have pursued DNVHC accreditation. DNVHC also provides accreditation services for critical access hospitals and offers certification in the disease management program/centers of excellence for primary and comprehensive stroke center certification.
The standards
The DNVHC NIAHO® accreditation program integrates the CoPs with the International Standards Organization 9001 Quality Management Systems-Requirements. DNVHC uses a survey approach that will look at the respective services and processes within the hospital and apply two different standards: one that is more prescriptively related to the CMS Conditions of Participation and the other to look at the overall quality management system to ensure that processes are being managed effectively.
Currently, there are 25 chapters in the NIAHO® manual. Most of the chapter names coincide with many of the section names in the CMS CoPs and departments or functions within a hospital. NIAHO® standards focus on outcomes and are less prescriptive than The Joint Commission. The standards are arranged in a format similar to the one used in the CMS CoPs. First the standard is listed, then the Standard Requirement, followed by the "Interpretive Guidelines," and lastly, the "Surveyor Guidance."
Changes to the NIAHO® standards can be broken down into two groups: mandatory and discretionary. Mandatory changes occur when NIAHO® standards are altered to conform to a change in the CMS CoPs. Discretionary changes clarify existing standards or incorporate practices and principles to enhance the NIAHO® accreditation program. Such changes occur through a thorough review process, involving input from the field and applicable agencies and review by DNVHC's accreditation management team.
The ISO 9001 Standard was introduced in 2000 and represented a combination of three standards to focus on process management. Minor revisions in 2008 addressed issues faced by facilities in service industries, including healthcare. Generally, ISO changes the standards no more frequently than every six years. The next revision set to be released is ISO 9001:2015
The survey process
Similar to the processes of CMS, as well as The Joint Commission and other accrediting organizations, NIAHO® surveys are conducted through tracer methodology, in combination with staff and patient interviews and a review of medical records. While surveying the hospital to the CoP criteria, DNVHC surveyors also ensure that hospitals are compliant with the ISO 9001 standard throughout clinical and non-clinical areas.
Surveys are conducted by at least two surveyors — a physician or registered nurse and a physical environment specialist. A generalist will be added to the surveyor complement for larger hospitals. For hospital systems, the number and mix of surveyors depends on how the system has structured its quality management system. If the hospital system adopts a single approach to quality management across its facilities, the number or surveyors and survey days is minimized.
DNVHC accreditation decisions are not determined by the number of survey findings. In other words, there is no "magic number" of findings or "tipping point" that will cause a hospital to be denied accreditation. Rather, after survey, hospitals receive a preliminary report from the survey team, followed within 10 business days by a final report. The hospital will then have 10 calendar days to submit a corrective action plan, if needed.
• For Category 1 nonconformities, the hospital also submits root cause analysis to determine what led to the nonconformity, and the actions taken to correct it, including performance measure(s) data, findings, results of internal audits or other supporting documentation, and timelines to attest that correction action measures have been implemented.
• For Category 2 nonconformities, validation implementation of corrective measures occurs at the next annual survey. Upon approval of the plan, DNVHC's accreditation committee makes a final accreditation decision, and the hospital's accreditation goes into effect on the last day of the survey. Note that Category 1 condition-level findings will require re-survey.
Upon the approval of an acceptable corrective action plan, and follow up survey when applicable for condition-level nonconformities, the accreditation committee will then make the decision for approval or denial of accreditation. The accreditation will be valid for three years from the effective date subject to annual surveys.
It is possible for hospitals to attain initial NIAHO® accreditation without being fully compliant with ISO 9001 standards at the time of survey. In fact, hospitals have three years in which to achieve compliance. DNVHC believes hospitals that have already obtained accreditation through another regulatory body, or have passed a CMS or state survey, are already well on their way to 1SO 9001 compliance. Full compliance is assured through a series of annual surveys that roughly follow this timeline:
• Year 1 – NIAHO® accreditation and introduction to ISO 9001
• Year 2 – NIAHO® accreditation and ISO 9001 pre-assessment survey (Much like a mock survey, the pre-assessment survey measures readiness and identifies any gaps in compliance.)
• Year 3 – NIAHO® accreditation and stage one ISO 9001 surveys (to confirm hospital readiness for an ISO 9001 Compliance/Certification Audit)
• Year 4 – NIAHO® accreditation and ISO 9001 compliance/certification audit
• Years 5 – NIAHO® accreditation and ISO 9001 periodic audit
• Year 6 – NIAHO® accreditation and ISO 9001 periodic audit
Benefits
DNVHC's approach to accreditation is designed to allow organizations to be innovative, as the standards are less prescriptive and best practice is encouraged. Through testimonials on the DNVHC website, some organizations appear to be seeing a transformational change to their quality management system as well as improved communication between leaders, staff, and physicians. DNVHC purports that staff are more involved and accountable for improving processes as they relate to important aspects of care, thus improving patient satisfaction. Having an extended timeline for achieving full ISO 9001 compliance seems to be one of NIAHO® accreditation’s distinguishing features. Because hospitals are given leeway to achieve compliance over time, they can avoid the rush to correct deficiencies that are not sustainable.
One myth that has circulated is that DNVHC disregards patient safety goals. Instead, their philosophy is that hospitals should develop individualized programs to address patient safety in their facilities. Thus, NIAHO® accreditation requires hospitals to be accountable to ensure that quality management processes are planned, managed, measured, documented and improved. DNVHC is working to change the "culture of accreditation" by creating partnerships with their accredited hospitals to collaboratively work together to focus on continual improvement, apply innovative methods for compliance and patient safety, and ensure the quality of care provided to their patients. At the same time, DNVHC holds the hospitals accountable to ensure they are compliant with their standards that also meet the CMS CoPs. This unique approach to the accreditation process has been very well received and is attributable to their growth.
Costs
Costs of NIAHO® accreditation fall into two general categories: preparation costs and survey costs. Preparation costs derive mainly from standards manuals and human resources necessary for achieving readiness. (NIAHO® Standards, Interpretive Guidelines, and Accreditation Process can all be downloaded for no charge at www.dnvaccreditation.com. The ISO 9001standards can be purchased at www.iso.org or www.asq.com.) Because the NIAHO® survey process involves yearly, on-site surveys to encourage readiness, DNVHC argues that hospitals will be able to avoid the "ramp-up" costs normally associated with other forms of accreditation. The thinking here is that more surveys lead to a better understanding of organizational readiness, and therefore fewer surprises and less need to quickly assign resources to address concerns.
In addition, DNVHC asserts that there are no indirect costs associated with NIAHO® accreditation. In fact, their literature cites, by way of contrast, the model of Joint Commission Resources, affiliated with The Joint Commission, which sells consulting and publications to hospitals to help them prepare and maintain Joint Commission standards. However, this model does not appear to be vastly different from DNVHC's own operation. DNVHC offers various free training resources, including webinars. The company also provides, at a cost, day- and week-long training programs, on-site programs for individual organizations and personal training and updates at any given hospital. These may, in fact, be considered indirect preparation costs. DNVHC does provide a unique program not provided by other accreditation organizations, in that one person from the organization can attend a training program on the NIAHO® and ISO 9001 standards at no charge.
Survey costs, as quoted by DNVHC, include all fees and expenses and are based on the number of surveyors and the length of the survey, which are usually determined based on the following factors:
• Size of the facility, based on average daily census and number of FTEs
• Complexity of services offered, including outpatient services
• Type of survey to be conducted
• Presence of special care units or off-site locations, and the distance from the main campus
All in all, NIAHO® accreditation by DNVHC provides a compelling option for hospitals seeking flexibility in meeting compliance standards and that may already have an inclination toward more industrial approaches to ensuring quality. More information about NIAHO® accreditation can be found at www.dnvaccreditation.com.
You can also learn more by reading the remainder of the "Accreditation Options" series. Read the previous installments on "Accreditation Options," which have explored accreditation as a strategic choice and describe other accreditation choices, including the Healthcare Facilities Accreditation Program and The Joint Commission.
Victoria Fennel has more than 20 years of healthcare leadership experience. She has spent the majority of her career in nursing leadership roles and brings expertise in evidence-based practice, nursing education, quality management, performance improvement, accreditation, risk management, patient safety and patient-centered care. As director of accreditation and clinical compliance for Compass Clinical Consulting, Ms. Fennel manages the quality of accreditation and compliance engagements and directs client education and advisement.