Promoting Continuous Readiness for

the Det Norske Veritas Accreditation

Survey

Catherine Woodall
KINS 4306
 Navicent Health Baldwin
• 140 bed, acute care facility
• Provides services to the 150,000 residents of Baldwin County
• Provides emergency services, radiology services, women’s services,
surgical services and general medicine
NHB Services
Ambulatory Care
Cardiac and Pulmonary Rehabilitation
Cardiopulmonary Testing
Diagnostics Cowles Clinic
*Emergency Room
*Intensive Care Unit
Laboratory Services
Radiology
Rehabilitation Services
*Skilled Nursing Unit
Sleep Center
Surgery Center
*Women's Services
 What is DNV?
• Originated in Norway in 1964 as a risk management company, Det
Norse Veritas
• Believed the current US accreditation had little impact
• Formed DNVHC and proposed an accreditation model that focused
on improvement and sustainability
• Utilizes the National Integrated Accreditation of Healthcare
Organization Requirements
 Survey Process
• Conducted through tracer methodology, in combination with staff
and patient interviews and a review of medical records.
• Conducted by a physician or registered nurse and a physical
environment specialist, along with a generalist in larger hospitals.
• After the survey, hospitals receive a preliminary report from the
survey team, followed within 10 business days by a final report. The
hospital will then have 10 calendar days to submit a corrective action
plan, if needed.
 Survey Process Continued
Category 1 nonconformities:
• root cause analysis must be submitted to determine what led to nonconformity
• Actions taken to correct it, including performance measures data, findings, internal audit
results, and timelines to attest that corrective action measures were implemented
• Condition-level findings will require re-survey

Category 2 nonconformities:
• Validation implementation of corrective measure occurs at the next survey

After approval of the corrective action plan, a final accreditation decision is made and goes into
effect.
 Why DNV?
• Allow organizations to be innovative
• Some organizations appear to be seeing improved communication
between leaders, staff, and physicians.
• Encourages staff to be more involved and accountable for improving
processes
• Extended timeline for achieving full ISO 9001 compliance seems to be
one of NIAHO® accreditation’s distinguishing features.
 My Role at NHB
• Quality Department under Amanda Crandall, the QI Data Analyst
• Prepare Documents, Plans & Minutes and Policies, Procedures &
Work Instructions for 2020 DNV Survey
• Performed routine Environment of Care audits in Nursing Services
• Utilized an existing Mass Alert System used for Emergency
Management to quickly convey DNV’s arrival to hospital leaders
• Assisted with the creation of educational materials for staff
 Internship Goals
• To promote Navicent Health’s Mission of “Together, we elevate health
and well-being through compassionate care”.

• To portray Navicent Health’s values of Integrity, Respect, Ownership

& Caring (IROC)

• To prepare for leadership through co-curricular leadership

experiences provided by GCSU
Documents Still Needing Revision
Everbridge Mass Alert
 EOC Audit Form
Navicent Health Baldwin EOC Audit Form
Unit: Date: Auditors:
Items to Check C NC N/A Notes
Boxes or supplies are kept at least 8” off of the floor
Clean items are bagged
Crash cart checked daily
Crash cart is locked
Department is free of expired supplies
Equipment is stored/stacked properly with 18” clearance under sprinkler head
Everyone except Patients & Visitors wearing Name Badges/Identification/ ISO badge
Eye wash log checked weekly
Glucometer dated (6 months), QC Solution (90 days)
Hallways clear except isolation/crash carts
Medications Secured
Multi-Dose vials dated (28 Days)
No bugs in lights
No drinks/food on computer on wheels or at nursing station
No dust on air vents
No dust on sprinkler heads
No lights out
No posted information without date and lamination
No stained ceiling tiles
No unattended carts contain patient information on screen
No unattended carts that contain dangerous items
O2 cylinders are properly secured in racks. (i.e. empty in empty racks)
Patient belongings not in soiled utility room
Patient foods stored in the patient refrigerator have name, room # and date
Personal protective equipment (PPE) is readily available where appropriate
Sharps container below fill line
Staff have safety eyewear in their possession
Other findings:
Non-Conforming Output Evidence
NHBEOC Audit Non-ConformingOutput Evidence
Unit: Date: Auditors:
Non-Conformities Pictures
 Sample OB EOC Audit Navicent Health Baldwin EOC Audit Form
Unit: OB Date: 2/ 24/ 2020 Auditors:Dana Hill, Cat Woodall
Items to Check C NC N/ A Notes
Boxes or supplies are kept at least 8” off of the floor x
Clean items are bagged x
Crash cart checked daily x
Crash cart is locked x
Department is free of expired supplies x
Equipment is stored/stacked properly with 18” clearance under sprinkler head x
Everyone except Patients & Visitors wearing Name Badges/Identification/ ISO badge x
Eye wash log checked weekly x
Glucometer dated (6 months), QC Solution (90 days) x
Hallways clear except isolation/crash carts x
Medications Secured x
Multi-Dose vials dated (28 Days) x
No bugs in lights x
No drinks/food on computer on wheels or at nursing station x
No dust on air vents x
No dust on sprinkler heads x
No lights out x
No posted information without date and lamination X Few notes on Nursing Station that need lamination
No stained ceiling tiles x
No unattended carts contain patient information on screen x
No unattended carts that contain dangerous items x
O2 cylinders are properly secured in racks. (i.e. empty in empty racks) x
Patient belongings not in soiled utility room x
Patient foods stored in the patient refrigerator have name, room #and date x
Personal protective equipment (PPE) is readily available where appropriate x
Sharps container below fill line x
Staff have safety eyewear in their possession x
Other findings:

Will discuss a time to audit Nursery and L&D with Marcie Pittman.

Notes: When entering C, NC or N/A , you must put a capital "X" in the appropriate column

Date Printed: 2/24/ 2020

Operating Room Audit
 Sample Restraint Log

AVG
Monthly Restraint # Patients Prolonged Use Nursing
December 2019 ER Behavorial Restraint Log Total Hours Hours (>24 hrs) MD Compliance # of Episodes Compliance # of pt injuries

46 9 0 100% 5 80% 0
Total Episode Timely Nursing Injuries
Month Reasonfor Order Start Stop Restraint Total Patient Behavioral Orders Timely MD Start Day of Staff Initiating Shift Documenation sustained by
Account # Year Age Sex Restraints (Date & Time) (Date & Time) (Date & Time) Hours Restraint Hours Renewed Q hrs Documentation MDType of Restraint Week Initiated Order Inititated Completed Patient/Staff
Dec-19 Behavioral 12/2/2019 11:35 12/2/2019 11:35 12/2/2019 17:35 6:00 Yes Yes Seclusion Monday Yes 7am-7pm Yes No
Dec-19 Medical 12/11/2019 02:00 12/11/2019 02:00 12/11/2019 07:55 5:55 N/A Yes Soft Limb (2) Wednesday Yes 7pm-7am Yes No
Dec-19 Medical 12/23/2019 15:38 12/23/2019 15:38 12/23/2019 18:25 2:47 N/A Yes Soft Limb (2) Monday Yes 7am-7pm Yes No
Dec-19 Medical 12/10/2019 06:50 12/10/2019 09:00 12/10/2019 19:00 10:00 N/A Yes Soft Limb (2) Tuesday Yes 7am-7pm Yes No
Dec-19 Medical 12/27/2019 18:50 12/27/2019 18:50 12/28/2019 16:50 22:00 N/A Yes Soft Limb (2) Friday Yes 7am-7pm No No
 DNV 2020 Checklist
DNV BOX-Yellow (Documents, Plans & Minutes)
Description Status Notes
Approved by QMS Dec 9, 2019: Utility Management Plan,
Physical Security Management Plan, Hazmat Plan, Fire Safety
Management Plan, Clinical Engineering Management Plan.

Need: Life Safety Plan and Annual Evaluation, Emergency

Management Plan and Annual Evaluation, EOP, General Safety
Plan and Annual Evaluation (System), Utility Plan Annual
Evaluation, Physical Security Management Plan Annual
Evaluation, Hazmat Plan Annual Evaluation, Fire Safety
Physical Environment Management Plans including most recent evaluations (Life Safety, Safety, Management Plan Annual Evaluation, Clinical Engineering
14 Security, Haz Mat, Emergency Management, Medical Equipment, Utilities) NEED Management Plan Annual Evaluation.
Hospital floor plan indicating locations for patient care and treatment areas (including swing
18 beds, distinct parts units, or PPS excluded units) NEED
19 Restraint Log IN PROGRESS
List of off campus care locations, provider based services and non-hospital services, with
21 addresses NEED
22 List of all clinical and non-clinical contracted services, including description of each NEED

MRI>OR scheduler desktop>Report>List Operator

20 Surgery/Procedure schedule (surveyor to sepcify case types, timeframe, and location) NEED DAY OF Change top from ORALL to ACUALLNH for amb care schedule

Amanda Crandall will provide Surveyors with any additional

23 Other documented information required by the Quality Management System NEED DAY OF information while they are here.
1 Hospital Org Chart Complete
2 Nursing Services Org Chart Complete
Nursing service plan of administrative authority/delineation of responsibilities for delivery of
3 patient care Complete
4 Leadership roster, including CEO, CNO and CMO Complete
Most recent reports of CMS/State Agency surveys, QMS audits, or accreditation surveys, unless
5 provided by DNV GL Complete October survey printed & in box.
 DNV 2020 Checklist
DNV BOX-RED (Policies, Procedures, Work Instructions)
Description Policy/ WI Individual Status Revision Date Folder Status
1a: printed 1a: 2/11/2020

WI 1a: Moderate Sedation: Sedation/Analgesisa, Administration for Procedures- 1b: 2/28/19

Adults 1b: printed
1c: 11/20/19
WI 1b: Consent for Anesthesia Services 1c: printed

WI 1c: Post Anesthesia Care Unit Admission/Reassessment Protocol 1d: 11/12/18

1d:printed
1 Anesthesia and all forms of sedation WI 1d: Anesthesia Bypas Post Anesthesia Care Unit Setting Guidelines COMPLETE
2 Autopsy Management of Patient Deaths 2a: printed 2a: 1/30/2019 COMPLETE
WI 3a: Blood Administration and Transfusion 3a: printed 3a: 11/21/18

WI 3b: Administration of Blood and Blood Components and Management of

3 Blood and Blood Product Admininstration Reactions 3b: printed 3b: 02/06/2020 COMPLETE
WI 4a: Case Mangement Scope of Services 4a: 12/19/19
4a:printed

4 Case Management WI 4b: Case Mangement Assessment and Plan of Care 4b:Printed 2/13/2020 4b: 12/17/19 COMPLETE
5 Discharge Planning WI 5a: Discharge Planning 5a: printed 5a: 12/19/19 COMPLETE
Verbal/Telephone Orders and order
6 authentication Medical Staff By Laws - Sherri Smith 6a: printed N/A COMPLETE
WI 7a: Discharge Patient Record Retrieval 7a: printed 7a: 1/9/2020

WI 7b: HIM Imaging Prep Process 7b: printed 7b: 1/9/2020

WI 7c: Medical Record Completion Policy 7c: printed 7c: 1/9/2020

WI 7d: Missing Record Notification 7d: printed 7d: 1/9/2020

WI 7e: Missing Date on History and Physical 7e: Printed 7e: 1/30/19

7 Medical Records Management

WI 7f: Filing of Incomplete Medical Records 7f: Printed 7f: 1/9/2020
COMPLETE
 Standards by Department
DNV Standards of Practice #of subStandards Department/Person Accountable Pages Notes
QM Quality Management (QM) 8 10-15 QM 7 are metricsthat must be reportedannuallyto QMS. Reviewandsee ifanyapplyto your department.
GB Governing Body (GB)
CE Chief Executive Officer (CE)
MS Medical Staff (MS)
NS Nursing Services 40-45 All Nursing departments look at NS. 1 Nursing Service and NS. 3 Assessment & Plan of Care (Pages 42-45)
SM. 3 isDepartment Scope ofService-Everydepartment needsto make sure theyhave this.
SM Staffing Management SM. 7 isStaffEvaluations-Make sure youhave completedyour requiredstaffevaluations
MM Medication Management
SS Surgical Services
SS. 4 History and Physical
AS Anesthesia Services
LS Laboratory Services
RC Respiratory Care Services
MI Medical Imaging
NM Nuclear Medicine Services
RS Rehabilitaion Services
ED Emergency Department
OS Outpatient Services
DS Dietary Services
PR. 1-5 Patient Rights
PR.6 Grievance Procedure
PR. 7 Restraint or Seclusion
PR.8 Restraint or Seclusion: Staff Training Requirements
PR.89 Restraint or Seclusion: Report of Death
IC Infection Prevention and Control
MR Medical Records Service
MR. 7 Required Documentation
DC Discharge Planning
UR Utilization Review
PE Physical Environment
PE. 5 Hazmat Management System
PE.7 Medical Equipment Management System
TO Organ, Tissue, and Eye Procurement
NIAHO Acute Standards Rev 18-2 01-21-2019
 Sample Falls Anaylsis
Factor Contributing Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 CY 19
Fall Risk interventions not implemented 1 1 0 1 1 0 0 4
Unidentified Cognitive Repairment/ Intermittent Confusion 1 1 0 0 1 1 0 4
Physical Impairment not identified 0 0 0 0 0 0 1 1
Syncope, arrest, seizure, faint-unanticipated phsyiological 0 0 0 1 0 0 0 1
Unaccompanied in bathroom, commode, or side of bed 1 0 1 0 2 0 1 5
Lack of constant observation/ 1:1 0 1 0 1 1 1 1 5
Staff member not assisting 0 0 0 0 1 0 1 2
Lifting/ assistive device not utilized 0 0 0 0 0 0 1 1
Family member assisting 0 0 0 1 0 0 0 1
Assistive device used incorrectly 0 0 0 0 0 0 0 0
Staffing or assignments not adequate 0 1 0 0 0 3 0 4
Staff not using equipment properly 0 1 0 0 0 0 0 1
Unaware of fall procedures 0 1 0 0 0 1 0 2
Aware but non-compliant with restrictions/ precautions 0 1 1 0 2 1 1 6
Fall Risk Status not communicated 1 0 0 0 0 0 0 1
Floor Mat Not in Use 1 1 0 0 1 0 1 4
Non-skid socks not used/wrong size 1 1 0 0 0 0 0 2
Malfunctioning equipment 0 0 0 0 1 0 0 1
Bed or chair alarm not on 0 1 0 1 1 0 1 4
Furniture or equipment problems 0 0 0 0 1 1 0 2
Floor wet/ clutter in room 0 0 1 0 0 0 0 1
Bed too high, incorrect # side rails 0 0 0 0 0 0 1 1
High Fall Risk Medications 2 1 3 0 1 2 3 12
Injuries 0 2 0 0 1 1 1 5
# Root Cause Debrief Forms 2 6 3 2 4 3 4 24
# falls per month (4PT, 3CT, ICU, OB) 2 5 4 11 8 6 4 40
 Sample Falls Analysis
Factor Contributing patient 1 patient 2 patient 3 patient 4
Unaccompanied in bathroom, commode, or side of bed x
Staff member not assisting x
Staffing or assignments not adequate x
Aware but non-compliant with restrictions/ precautions x x
Floor Mat Not in Use x
Malfunctioning equipment x
Furniture or equipment problems x x
High Fall Risk Medications x x
# falls per month with injury (4PT, 3CT, ICU, OB)
 Navicent Health Baldwin Leadership Team
Todd Dixon CEO

Todd Cox AVP Finance

Paul Barkley COO

Dr. Douglas Brewer CMO

Lorraine Daniel Chief Nursing Officer

Directors
Elaine Dixon Director of Revenue Cycle

Tammy Everett Director of Radiology

Wendy Newsome Director of Perioperative Services

Siggy Tetteh Director of IT Rural Health Areas

Terry Hall Director of Nutritional Services

Mark Christmas (Interim) Emergency Department

Managers
Carol Babb Pharmacy

Karen (Katy) Adams Centralize Scheduling

Wendy Weygant Sleep & Wellness

Marcie Pittman 3OB/ Women’s Center

George Chiasson BIOMED

Lisa Donnelly Accounting

Gil Gilliland Materials Management

Janet Green Health Information

Sherry Hussey Case Management

Laura Matthews Cardiac-Rehab

Greg Seals Cardiopulmonary

Heather Smith Physical Therapy

 PolicyTech HowTo
• PowerPoint created to educate staff on:
• Accessing PolicyTech
• Browsing PolicyTech for documents
• Adding documents to favorites for easier access
• Finding and completing tasks assigned by managers
 Scribe Training
• Created DNV Scribe Escort List and Responsibilities form
• Distributed ‘Survey Etiquette for Staff’ template to departments
• Trained scribes on duties, expectations and day of procedures
Skills Fair: Infection Control Education
 PolicyTech Requested Forms for 2021
Current Revision
Policy/Work Instruction/Form Name Reviewer Approver Date Effective Date Next Revision Date Version # Category (DNV)
Moderate Sedation: Sedation/Analgesisa, Administration for
Work Instruction Procedures-Adults Wendy Newsome Lorraine Daniel 2/11/20 1/19/19 2/11/21 3 Anesthesia and all forms of sedation

Form NHB Anethesia Consent 2/28/19 2/28/21 2 Anesthesia and all forms of sedation

Work Instruction Post Anesthesia Care Unit Admission/Reassessment Protocol Wendy Newsome Lorraine Daniel 11/20/18 11/20/18 11/20/20 2 Anesthesia and all forms of sedation
Work Instruction Anesthesia Bypass Post Anesthesia Care Unit Setting Guidelines Wendy Newsome Lorraine Daniel 11/12/18 1/1/19 11/12/20 2 Anesthesia and all forms of sedation
Work Instruction Management of Patient Deaths Patsy Hicks Lorraine Daniel 1/30/19 1/30/19 1/30/21 2 Autopsy
Policy Blood Administration and Transfusion Julie Bailey Keath Wade 11/21/18 11/21/18 11/21/20 2 Blood and Blood Product Admininstration
Administration of Blood and Blood Components and Management
Work Instruction of Reactions Mandy Nuhfer Lorraine Daniel 2/6/20 2/27/19 2/6/21 2 Blood and Blood Product Admininstration
Work Instruction Case Mangement Scope of Services Sherri Hussey Lorraine Daniel 12/19/19 12/3/18 12/19/20 2 Case Management
Work Instruction Case Mangement Assessment and Plan of Care Sherri Hussey Lorraine Daniel 12/17/19 12/3/18 12/17/20 2 Case Management
Work Instruction Discharge Planning Sherri Hussey Lorraine Daniel 12/19/19 12/5/18 12/19/20 3 Discharge Planning
Document Medical Staff By Laws - Sherri Smith Sheri W. Smith May-19 Oct-19 N/A Verbal/Telephone Orders and order authentication
Work Instruction Discharge Patient Record Retrieval Elaine Dixon Todd Cox 1/9/20 10/4/18 1/9/21 2 Medical Records Management
Work Instruction HIM Imaging Prep Process Elaine Dixon Todd Cox 1/9/20 10/18/18 1/9/21 2 Medical Records Management
Policy Medical Record Completion Policy Elaine Dixon Todd Cox 1/9/20 11/26/18 1/9/21 2 Medical Records Management
Work Instruction Missing Record Notification Elaine Dixon Todd Cox 1/9/20 1/30/19 1/9/21 2 Medical Records Management

Work Instruction Missing Date on History and Physical Janet Green Judy Ware 1/30/19 1/30/19 1/30/2021- change approver 1 Medical Records Management
Work Instruction Filing of Incomplete Medical Records Elaine Dixon Todd Cox 1/9/20 1/30/19 1/9/21 2 Medical Records Management
Medication Management, Administration, Safety, Security,
Work Instruction Inpatient Drug Formulary Carol E Babb Paul Barkley 1/18/18 1/18/18 1/18/21 2 Formulary
Medication Management, Administration, Safety, Security,
Work Instruction Inpatient Medication Dispensing Carol E Babb Paul Barkley 1/18/18 1/18/18 1/18/21 1 Formulary
Medication Management, Administration, Safety, Security,
Work Instruction Ordering and Transcribing of Medications Carol E Babb Paul Barkley 4/18/19 9/23/18 4/18/21 4 Formulary
Medication Management, Administration, Safety, Security,
Work Instruction Medication Order Review and Verification Carol E Babb Paul Barkley 9/18/18 9/18/18 9/18/20 1 Formulary
Medication Management, Administration, Safety, Security,
Document DNV Guide to Work Instructions for Pharmacy N/A Formulary
Medication Management, Administration, Safety, Security,
Work Instruction NHB Medication Administration Carol E Babb Paul Barkley 10/11/19 5/1/19 10/11/20 3 Formulary
Work Instruction Donation: Organ, Eye and Tissue Wendy Newsome Lorraine Daniel 1/31/19 1/31/19 1/31/21 2 Organ, Tissue and Eye Procurment