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Accrediting Agencies: Who they are and what you need to know

By Deb LeMay, regulatory affairs manager, TriMedx

Three accrediting bodies exist that meet the conditions of participation under the requirements of the Center for Medicare & Medicaid Services (CMS). Most hospitals are familiar with Joint Commission and Healthcare Facility Accreditation Program accreditation standards. However, the newest player in the field is Det Norske Veritas.

Currently Ball Memorial Hospital is the first ISO Certified and NIAHO Accredited hospital in the State of Indiana. According to Claire Lee, RN, MSN, CNAA, CPHQ, Ball Memorial Hospital’s DNV representative/auditor, DNV (NIAHO and ISO) standards are not much different from what facilities currently experience during an inspection. The TJC Medical Equipment Management Plan is based on the CMS Conditions of Participation, as are the DNV standards.

Some major differences posed by NIAHO Accreditation and ISO Certification that affect medical equipment management plans include:

1. Internal audits required yearly
   Each department must complete an internal audit and submit Corrective Action Plans for Quality Improvement. Plans are reviewed by the NIAHO and ISO auditors during the annual inspection.
2. Document control
   All documents, forms, policies, procedures, work instructions, doctor orders and records must be updated and only current versions available to staff, which can be extremely labor intensive.
3. Monitoring and measuring
   Constant verification by trending/statistical data to ensure that any device that has an influence on results/outcomes or affects workflow has to have documentation assuring it’s accuracy. Example: Temperature on a refrigerator; there are daily logs that indicate that the refrigerator temperature was recorded and remains within a certain range, but is the thermometer is accurate? (Other examples: Scales and Flow meters) Need to conduct random inspections on the thermometer to document accuracy of calibration. All equipment - regardless of PA schedule that produces usable output to make judgments/decisions will need to be randomly audited to insure accuracy of calibration.
4. Inspection questioning process
   DNV will evaluate the standards of your work process. Tell the inspector what you do, show them how you do it, and be able to produce documentation of the process. All work instructions must be documented and updated (i.e.; If you were not to come to work, someone could follow a set of instructions and do your job). Staff must know the policies and procedures and follow them as written.
   
   View a matrix comparing each agency.