QUALITY: Driven through Accreditation

Susi VonBergen, RNClinical Informatics

Nemaha County Hospital

Who we are… 16 bed Critical Access Hospital Average census 3.7 Acute, SNF, ER Outpatient Clinics & Therapies Home Health 90 FTEs

WHAT is DNV?• Established in 1864• Independent, self-supporting

Foundation• Tax paying entity (in every country it

operates)• 300 Offices in 100 Countries• 9000 Employees (locally employed)• Operating in the U.S. since 1898

The DNV Purpose

Safeguarding life, property and the environment

DNV Values

We build trust and confidence We never compromise on quality or

integrity We are committed to teamwork and

innovation We care for our customers and each

other

WHY did we chose DNV as our accreditation vehicle?

DNV Mantra

• Say what you do• Do what you say

• Prove it• Improve it

WHY did we chose DNV as our accreditation vehicle?

• Meets and exceeds CoP requirements• Includes ISO 9001 QMS (proven basis for

continual improvement• No additional staff required to implement

DNV/NIAHO• Annual visits – added accountability• Focus on sequence and interactions of processes

throughout the hospital

• Leads to improvement of patient safety and quality of care

WHY did we chose ISO9001 Certification?

• Organizational approach to implementing Quality processes• Integrate all hospital

processes to improve patient care and experience

WHY did we chose ISO9001 Certification?

• Establish a Quality Management System• Heavy emphasis on Leadership

and accountability• Cost savings by optimizing

operations• Annual surveys and annual

internal audit processes

What we gained from implementing ISO 9001

Improve the quality “system” to reduce errors and improve performance

Improve the effectiveness and efficiency of processes that enable errors and are hindered with complexity

Increase patient satisfaction Learn from and benefit from the successes ISO

9001 QMS has produced in other sectors, especially the service industry

A New Accreditation Model

Ensuring that Quality and Patient Safety is Managed, Not Just Measured

The Infrastructure… The inherent requirements for process

improvement result in good outcomes specified in the CMS Conditions of Participation

Hospitals are held accountable through the mechanisms required in ISO 9001 for Internal Audits, Management Review and Corrective / Preventative Action

Allows hospital innovation to determine HOW to assure sustainable and safe best practices that support this approach

Processes… Quality Policy = Mission, Vision Quality Objectives = Organization’s Quality Goals &

Objectives Corrective Action = CQI/PI Process – RCAs Preventive Action = FMEA Process Internal Audit = Review of departmental &

organization processes and outcomes; individual performing cannot come from area being audited

Document Control = Policies, Forms, Standing Orders, etc.

Management Review = Quality Director Management Review = Enlarged Quality Committee

Function

And now we are Movie Stars

CONTACT INFO

Susi VonBergen, RNClinical Informatics

2022 13th StreetAuburn, NE 68305

402-274-6151svonbergen@nchnet.org