Weighing accreditation options

Accreditation Connection, May 4, 2009

It has been a little over six months since Det Norske Veritas (DNV) was awarded hospital deeming authority by the CMS and Greeley clients have been asking whether DNV is a realistic alternative to Joint Commission accreditation. Our answer: It depends.

CMS seems to approve of the DNV process since it awarded DNV deeming authority for four years, rather than the year or two expected. A dozen or so hospitals have already become accredited by DNV (see the story of one such hospital on p. NN), with another 100 or so in the queue, indicating respectable traction for a newcomer.

We have mixed results when we compare the NIAHO standards (as DNV’s accreditation program is formally called) with the Conditions of Participation and Joint Commission requirements.

For example, DNV does not have a prescriptive set of patient safety goals (a large contributor to requirements for improvement during Joint Commission surveys), relying instead on the hospital’s own data to set priorities for and approaches to patient safety. Like the Conditions of Participation, NIAHO standard QM.7 requires internal reviews or audits (which may be met through ongoing data collection) of all internal and contracted departments and services at scheduled intervals. QM.7 also lists 18 subjects for data collection. A few of these subjects are new (although some readers may have been collecting them anyway): medication reconciliation, the use of dangerous abbreviations, the effectiveness of the pain management system, and patients held in the emergency department or postanesthesia recovery area longer than eight hours.

The annual DNV surveys seem to have the advantage of maintaining momentum, continuity (with the same surveyors coming back for repeated visits), and predictability. On the other hand, they are annual.

There also seem to be few external roadblocks to choosing DNV, since health plans and residencies have so far accepted the accreditation without reservation. So, how do you choose? It truly depends on your hospital’s situation. However, we continue to view the addition of DNV as a win for clients regardless of which accreditation they ultimately choose. Competition is good for customers and strengthens the competitors. It’s as simple as that.

Bud Pate, REHS, is vice president of content and development with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. For more information on The Greeley Company, visit For more information on Briefings on The Joint Commission, click here.

Most Popular