CUSTOMER 4.0 Quality Management System 5.0 Management responsibility 4.1 4.2 4.1 General (4.2) 4.1.f Continual Improvement* 4.2 Document requirements 4.2.2 Quality Manual (4.2) Justification & process flow diagram* 4.2.3 Documentation (4.5) 4.2.4 Records (4.16) 5.1 5.2 5.3 5.4 5.5 5.6 5.0 Management responsibility CUSTOMER 8.1 8.2 8.3 8.4 8.5 8.0 Measurement, analysis and improvement CUSTOMER 6.1 6.2 6.3 6.4 6.0 Resource management 5.1 Management commitment (4.1) 5.2 Customer focus* 5.3 Quality Policy (4.1)* 5.4 Planning (objectives) 5.5 Responsibility & authority (4.1) 5.5.3 Internal Communication* 5.6 Management review (4.1) 8.1 General 8.2 Monitor & measure 8.2.1 Customer Satisfaction* 8.2.2 Internal audit (4.17) 8.2.3 Processes* 8.2.4 Product (4.10) 8.3 Nonconforming product (4.13) 8.4 Analysis of data * 8.5 Improvement 8.5.1 Continual* 8.5.2 Corrective (4.14) 8.5.3 Preventive (4.14) 6.1 Resources (4.1) 6.2 Human Resources (4.18) 6.3 Infrastructure (4.9) 6.4 Work environment (4.9) 7.0 Product realization 7.1 7.2 7.3 7.5 7.4 7.6 INPUT OUTPUT 7.1 Planning and product realization (4.2 & 4.10) 7.2 Customer related 7.2.1 Determine requirements* 7.2.2 Review requirements (4.3) 7.2.3 Customer requirements* 7.3 Design & development (4.4) 7.4 Purchasing (4.6) 7.5 Production (4.7, 4.8, 4.9. 4.12, 4.15) 7.6 Calibration (4.11) © Det Norske Veritas AS. All rights reserved

Process Mapping Pre-Admission 2 Referral 4.2 Documentation Requirements 5.0 Management Responsibility 6.1 Provision of Resources 6.2 Human Resources 6.3 Infrastructure 6.6 Work Environment 7.4 Purchasing 8. Measurement, Analysis & Improvement Process Mapping Referral Organizational Structure Management & Support Pre-Admission Review of Service Capabilities 5.2 Customer Focus 7.2 Customer Related Processes Resources Staff & Equipment ( Including Training) 5.2 Customer Focus 5.4 Planning 7.2 Customer Related Processes 6.2 Human Resources 6.3 Infrastructure 6.4 Work Environment Admission (Assessment / Diagnosis) Support Services (Dietary, Housekeeping, Buildings & Grounds) 5.2 Customer Focus 7.2 Customer Related Processes 7.3 Design & Development (Research Hospital) 6.3 Infrastructure 6.4 Work Environment 7.1 Planning and Service Realization 7.5 Production & Service Provision 7.6 Control of Monitoring & Measuring Devices 8.2.3 Monitoring & Measurement of Processes 8.2.4 Monitoring & Measuring of Service Development of Care / Treatment Plan Performance Monitoring & Review Delivery of Care Service Improvement 7.1 Planning & Service Realization 7.4.3 Verification of Purchased Product 7.5.1 Control of Product & Service Provision 8. Measurement, Analysis &Improvement On-going Monitoring and Measurement External Input: DOH CMS (COPs) HFAP Change Care / Treatment Plan as Appropriate 8.3 Control of Non-Conforming Service 8.4 Analysis of Data 8.5 Improvement Discharge / Long Term Care 4.2.4 Control of Records 8.2.1 Customer Satisfaction © Det Norske Veritas AS. All rights reserved 08 November 2018 2

Process Map Example © Det Norske Veritas AS. All rights reserved 08 November 2018

Hospital Sequence and Interaction of Processes © Det Norske Veritas AS. All rights reserved 08 November 2018