QUALITY: Driven through Accreditation Susi VonBergen, RN Clinical Informatics Nemaha County Hospital

 16 bed Critical Access Hospital  Average census 3.7  Acute, SNF, ER  Outpatient Clinics & Therapies  Home Health  90 FTEs

Established in 1864 Independent, self-supporting Foundation Tax paying entity (in every country it operates) 300 Offices in 100 Countries 9000 Employees (locally employed) Operating in the U.S. since 1898

Safeguarding life, property and the environment

 We build trust and confidence  We never compromise on quality or integrity  We are committed to teamwork and innovation  We care for our customers and each other

DNV Mantra Say what you do Do what you say Prove it Improve it

Meets and exceeds CoP requirements Includes ISO 9001 QMS (proven basis for continual improvement No additional staff required to implement DNV/NIAHO Annual visits – added accountability Focus on sequence and interactions of processes throughout the hospital Leads to improvement of patient safety and quality of care

Organizational approach to implementing Quality processes Integrate all hospital processes to improve patient care and experience

Establish a Quality Management System Heavy emphasis on Leadership and accountability Cost savings by optimizing operations Annual surveys and annual internal audit processes

 Improve the quality “system” to reduce errors and improve performance  Improve the effectiveness and efficiency of processes that enable errors and are hindered with complexity  Increase patient satisfaction  Learn from and benefit from the successes ISO 9001 QMS has produced in other sectors, especially the service industry

Ensuring that Quality and Patient Safety is Managed, Not Just Measured

 The inherent requirements for process improvement result in good outcomes specified in the CMS Conditions of Participation  Hospitals are held accountable through the mechanisms required in ISO 9001 for Internal Audits, Management Review and Corrective / Preventative Action  Allows hospital innovation to determine HOW to assure sustainable and safe best practices that support this approach

 Quality Policy = Mission, Vision  Quality Objectives = Organization’s Quality Goals & Objectives  Corrective Action = CQI/PI Process – RCAs  Preventive Action = FMEA Process  Internal Audit = Review of departmental & organization processes and outcomes; individual performing cannot come from area being audited  Document Control = Policies, Forms, Standing Orders, etc.  Management Review = Quality Director  Management Review = Enlarged Quality Committee Function

CONTACT INFO Susi VonBergen, RN Clinical Informatics th Street Auburn, NE