Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast.net

1. Welcome to the MHQP & HealthForce MN Quality Brownbag Room Monthly Noon Brownbag Fourth Thursday Every Month March 25th What’s DNV ? Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast.net Slides are posted at: http://www.healthforceminnesota.org/pages/Programs/courses.html

2. Hopefully you provided your name & organization when you signed in. If so: Just say Hi in the Chat Pod and we’ll capture your name and organization in the log. If not: identify yourself and organization in the Chat Pod to the left of your screen. Register your Attendance

3. Rural / Outstate ? Metropolitan area ? Organization that has (or serves) both ? Poll: Who is Attending this Session ?

4. Healthcare system Hospital Clinic or Clinic System Long term care Healthplan Homecare / Hospice A Quality Support Organization Other ? (Identify other in Chat Pod) Poll: Who is attending: Organization Type ?

5. 1 2 3 4 5 6 7 >7 Poll: How many total participating in your room ?

6. I am a healthcare quality professional and am interested in additional education. I am a healthcare professional interested in developing quality skills as a core competency. I am a healthcare professional interested in learning more about healthcare quality. Poll: What do you hope to gain by participating?

7. What’s DNV ? Follow-up to the November 2009 Brownbag Baldrige – TJC - Magnet

8. Panel Questions • How did you first hear about  DNV ? • Has your organization assessed DNV as an option ? • If so,  why did your leadership feel it was worth committing resources to do an assessment ? • What was the outcome of that assessment ? What are your next steps ?

9. Allina ‘s response from Mary GavinDirector, Allina Hospital Regulatory Accreditation • A team of Allina regulatory accreditation experts conducted a comprehensive evaluation of DNV last Fall.  A decision was made by Sr. Leadership to not pursue DNV at that time.  The decision was based on the fact that Allina is planning on doing an evaluation and redesign of quality.  It was felt that a strong quality leadership platform was necessary before any change in our accrediting organization could be implemented.  Thought: Looking at this from another perspective, it could be the opportunity to provide structure for the redesign of quality. • How did you first hear about  DNV ?    • CMS Federal Register, • Federal Register / Vol. 73, No. 81 / Friday, April 25, 2008 / Notices Medicare and Medicaid Programs; The Det Norske Veritas Healthcare, Inc (DNV) for Deeming Authority for Hospitals • Modern Healthcare, October 27, 2008 Front Page Article • DNV website

10. NAHQ e-news March 2010Q&A with Darrel Scott DNV SVP legal & regulatory affairs • Based on ISO 9001 standards • You don’t get ready or “ramp up” (thought: Baldrige like) • Annual improvement reviews: more collaborative • 100 hospitals in the queue; plan is to double this year • Expectation is ISO 9001 compliant within 3 years • An ISO organization defines its processes • Rip out hospital information silos • Audits conducted by someone from another department • Systemic process reviews improve communication

11. DNV FAQ’s • Det Norske Veritas : Norwegian Company • US offices in Cincinnati & Houston • Deemed status September 2008 • ISO compliance not required for accreditation but expected within 2 years of first survey • ISO • 9001 applies to service industries • Changes standards every 6 years (but DNV must implement CMS Conditions of Participation [CoP] within 30 days) • Approach: Tracer Methodology (Wonder who was first ??)

12. DNV Accreditation Progression • 1st visit: • Get Accredited to NIAHO℠ - meet the requirements of CMS • Get a gap analysis to ISO 9000 with the road map to achieving it within a maximum of 2 years • 2nd visit – 1 year after accreditation • Continue accreditation by undergoing an survey to NIAHO℠ • Survey for progress in implementing ISO 9001 • If in compliance with ISO 9001 – a statement included in Certificate of Accreditation • May choose to demonstrate compliance by obtaining a separate ISO 9001 certificate • 3rd visit – • Continue accreditation by undergoing survey to NIAHO℠ • Be in compliance with ISO 9001

13. ISO 9000 (9001) • Addresses Quality Management System • Scope Baldrige • Customer contracts (Cat 3) • Hiring & employee training (Cat 5) • Design & development of products & services (Cat 6, 3) • Production & delivery of products & services (Cat 6) • Selection & managing of suppliers (Cat 6) • Management responsibility (Cat 1) • Internal quality audits (Cat 6) • Monitoring & measuring (Cat 4 & 7) • Continual improvement (Cat 4) • Corrective and preventive action(Cat 6)

14. DNV: Benefits of ISO 9001 • Provide a common framework for coordination and communication between departments/units • Improve systems, processes, efficiency and effectiveness • Consistently meet patient’s stated and implied needs • Provide evidence of a safe environment for patients • Increase productivity and financial performance • Improve consistency • Increase patient satisfaction

15. NIAHO℠ Standards - Chapters National Integrated Accreditation for Healthcare Organizations (DNV’s hospital accreditation program) • Medication Management • Surgical Services • Anesthesia Services • Laboratory Services • Respiratory Care Services • Medical Imaging • Nuclear Medicine Services • Discharge Planning • Utilization Review • Physical Environment • Organ, Eye and Tissue Procurement • Quality Management System • Governing Body • Chief Executive Officer • Medical Staff • Nursing Services • Staffing Management • Rehabilitation Services • Obstetric Services • Emergency Department • Outpatient Services • Dietary Services • Patient Rights • Infection Control • Medical Records Service 03 April 2014

16. Comparison

17. Questions ?

18. Welcome to the MHQP & HealthForce MN Quality Brownbag Room Monthly Noon Brownbag Fourth Thursday Every Month April 22 Panel: Rapid Cycle / Continuous Improvement Questions? Contact: Skip Valusek MHQP Education Chair skipvalusek@comcast.net Slides are posted at: http://www.healthforceminnesota.org/pages/Programs/courses.html