A New Era in Psychiatric Hospital Accreditation: Four Questions for DNV GL Healthcare

By Claire Thayer, November 19, 2020

Recently, we hosted a Healthcare Web Summit webinar discussion with DNV GL Healthcare to learn about why CMS awarded it 4 years of deeming authority to provide accreditation services to Psychiatric Hospitals. We caught up with DNV GL Healthcare’s Thomas Quinn and Barry Smith on four key takeaways from the webinar:

1. Why did CMS award DNV GL Healthcare 4 years of deeming authority to provide accreditation services to Psychiatric hospitals?

DNV GL Healthcare: CMS will deem an organization between 2 and 6 years for the accreditation service that they are providing. Four years seems to be our initial experience with any newly deemed service we have offered.

2. What are some of the types and different roles for Surveyors?

DNV GL Healthcare: There are 3 different surveyors on each annual survey. We have our clinical surveyor, our generalist surveyor and our physical environment surveyor. The clinical surveyor is going to be focused on patient care units, the clinical setting, chart review, seeing what is going on in a unit, and observing patient and staff interactions. The generalist surveyor is focused on quality management issues, how your quality management system functions, medication management, and they are also involved in reviewing competency and utilization review. The Physical Environment surveyor’s role is to look at the entire physical plant of the organization – they will look at HVAC, fire drills, emergency management, biomed, safety and more.

3. Briefly tell us more about the accreditation process and what can Psychiatric hospitals expect in terms of onsite involvement?

DNV GL Healthcare: The accreditation process begins with the hospital completing a confidential application at no charge.  Once the hospital accepts the pricing and terms, DNV GL Healthcare will add the hospital to our schedule for an unannounced survey.  Initial surveys will consist of an onsite survey by a DNV GL Healthcare survey team.

The NIAHO® and ISO surveys are done together through Tracer Methodology as well as staff and patient interviews. While surveying the hospital to the NIAHO® Requirements, DNV GL Healthcare surveyors also ensure the application of the ISO 9001 standard. Tracer Methodology has been a staple of ISO 9001 audits since ISO 9001’s inception in 1987. All areas of the hospital are surveyed, both clinical and non-clinical. The number of surveyors and the mix of qualifications are determined specifically for each hospital and type of survey being performed. 

The hospital will receive a final report from DNV GL Healthcare within ten business days. The hospital will then have ten calendar days to submit its Corrective Action Plan with timelines for implementation. Once the Corrective Action Plan has been approved, the documentation is submitted to the Accreditation Committee for the final accreditation decision. 

Upon approval by the Accreditation Committee, DNV GL’s accreditation is typically effective on the date of receipt of an approved corrective action plan.  Individual survey results vary and certain circumstances may impact the initial accreditation effective date.  For hospitals new to the Medicare program, or applying for new provider status, the effective date for Medicare participation is always determined by CMS.

4. Where can we learn more about your standards and what's included in the application process?

DNV GL Healthcare: You can view and download all of our standards free of charge at this link: https://www.dnvgl.us/assurance/healthcare/standards.html  

You can also contact us at contacthc@dnvgl.com to request a short conversation to go over the application process and what all you will need to have in order to apply for DNV GL Psychiatric Hospital Accreditation.  Again, all of our standards are available at no charge as is the application.

If you missed this informative webinar presentation, Psychiatric Hospitals Now Have a Choice on Who They Partner With for Their Accreditation, we invite you to watch the full On-Demand webinar video or short webinar re-cap video.