dnv accreditation vs joint commission dnv accreditation vs joint commission

DNV has a client drop box feature where questions regarding the standards can be asked directly to our specialists and surveyors. 1350 0 obj <>stream WebThis background is fascinating in view of The Joint Commissions (TJC) history. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. Psychiatric Hospitals are accredited for a three year period, subject to annual survey to verify continuing compliance with NIAHO. Senior Account Executive . 127 30 Learning happens when staff are comfortable and not intimidated by the process. All Rochester Regional Health labor and delivery hospitals. 2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. 0000009113 00000 n DNV: Det Norske Veritas: DNV: Der Norske Veritas: DNV: District of North Vancouver (British endstream endobj 139 0 obj <>stream Top management should be involved at this stage. LAUREL, MS, South Central Regional Medical Center (SCRMC) announces the successful completion of its new accreditation process that has been awarded by DNV. The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. %PDF-1.6 % Accreditation | Det Norske Veritas (DNV) NIAHO Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Revision 7, 2008. It is widely recognized as the gold standard in healthcare accreditation, and its standards are considered rigorous and comprehensive. We evaluate how well your management system supports your focus areas. As DNV hospitals often say, ISO provides the structure for the staff to focus on xb```f``ue` ea *(ltSa{+ 9QQ (MHKX*?6Y ,8v'83rXrE0C;;[70^} Ua vHCO4@ZT Dr g$ Through its broad experience and deep expertise, DNV advances safety and sustainable performance, sets industry benchmarks, drives innovative solutions. DNVs accreditation program, called NIAHO (Integrated Accreditation of Healthcare Organizations), involves annual hospital surveys instead of every three years and encourages hospitals to openly share information across departments and to discover improvements in clinical workflows and safety protocols. cuup}c~*_3:!RvpgI(@6a^@IiPo}f$@ L9qdzD AY:RR' 4PQqhxitI3\! We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. 156 0 obj <>stream 0000013305 00000 n Why? ISO is the International Organization for Standardization. 0000006807 00000 n South Central Regional Medical Center was the first hospital in Mississippi to be accredited by DNV Healthcare. 0000001195 00000 n This product includes updates that will be made by NAMSS over the next 12 months. Available at: http://cert.branswijck.com/. Select from the topics below to get started. TCI certification. endobj Det 630-792-5509 | rzordan@jointcommission.org. Author Frederick P Franko. 1327 0 obj <> endobj View our list of disease-specific and specialty program certifications. hYmo6+bwRPI-@fulAMTcg5~w'I :^xXoay-uL3,%a8J#!%@aY%I>)ddJ:ph+*jX 9Q43F:\RzvYV:ibv2gTM]oWjQ)|V?AtYuy[uq]{ When found compliant, we issue the certificate. WebThis electronic reference tool provides plain-language interpretations of the credentialing standards for The Joint Commission, NCQA, Healthcare Facilities Accreditation Fundao So Francisco Xavier / Hospital Mrcio Cunha. 0000038715 00000 n WebThe JCAHO and its accreditation programs are described, the history of the Medicare-JCAHO relationship is reviewed, and why the federal Medicare program has relied on accreditation as an indicator of the quality of participating hospitals is examined. Reflective of an organizations performance with respect to Joint Commission standards and elements of performance (EPs).Transparent all components of the process are fully disclosed to accredited and certified organizations.Easily understood by all involved parties.More items ".*RK6"zf9ss~3 AARJA=Z\&6c@+|dk{GKY B_],IEmmq_rS}gX;L9nL%)5Ek&$;mcUeEP*wb\yaA.eW:OS3hoRqgi^Ygv`l!7/vou$VZ(T&d$iq-kUh_4<7\R+vi)e35elpG[piiqN#@t9Z]Y?})#=[8GOCb+1QKU,HY WWcVr y"=uOsb%V xOy^N?+OHG'9%[qdF]guPa("2Hbs=Kt0 :J~O|JGn n~ WebAssistant Director - Accreditation Services . %%EOF Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? DNV has a transparent procedure for suspension or withdrawal of certificates. 0000002975 00000 n For more information about DNV, visit www.dnvcert.com/healthcare. 630 2010 Mosby, Inc. Our surveyors employ a variety of methods for assessment, including staff interviews, medical record review, organizational document review, building and offsite visits, as well as patient interviews and feedback. Accreditation Canada accredited its first organization internationally in 1967 in Bermuda. %PDF-1.6 Antibiotic Susceptibility | Clifton Springs Hospital and Clinic recently was awarded an A grade for safety. 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. As an example, a hospital could have its Joint Commission accreditation renewed for three years on July 10, 2010. Following a positive decision you will receive the certificate shortly thereafter. At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. Rex Zordan . Accessed August 5, 2009. wG xR^[ochg`>b$*~ :Eb~,m,-,Y*6X[F=3Y~d tizf6~`{v.Ng#{}}jc1X6fm;'_9 r:8q:O:8uJqnv=MmR 4 The report indicates if your organisation is ready to proceed with the certification audit. Delia Constanzo . 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. 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.