QUALITY: Driven through Accreditation Susi VonBergen, RN Clinical Informatics Nemaha County...
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Transcript of QUALITY: Driven through Accreditation Susi VonBergen, RN Clinical Informatics Nemaha County...
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