In order for a hospital to display their commitment to high-quality, comprehensive patient care, proper accreditation is now more important than ever. In fact, many consumers look for it when choosing a hospital for services, and many practitioners look for it when choosing a hospital to work at.
There are some types of healthcare facilities where accreditation isn’t essential, and is just used as a competitive advantage. Hospitals aren’t one of them. In a hospital setting, accreditation is an expectation rather than a way to stand out. For this reason, a majority of hospitals hold accreditation status from at least one of the following accrediting agencies: Det Norske Veritas, Inc. (DNV), Healthcare Facilities Accreditation Program (HFAP), and The Joint Commission.
DNV vs. HFAP vs. Joint Commission: What’s the Difference?
Although each of these accrediting organizations have applied for and received “deeming authority” from the Centers for Medicaid and Medicare Services (CMS), they all do different things and are enforced in different ways. Below, we’ll walk through the differences between each of them and provide all the information hospitals, hospital managers, nurse managers, and more need to know about them.
DNV
DNV’s organizational purpose is to safeguard life, property, and the environment. As an accrediting organization, it has two goals: to access compliance and educate hospitals in best practices. Since receiving deeming authority from CMS back in 2008, DNV has accredited almost 500 hospitals across the United States.
DNV is governed by a team of degreed professionals, all with varying areas of expertise and years of experience. With clinical and management healthcare personnel, health lawyers, and engineers with extensive knowledge on ISO certifications, the DNV accreditation management team has a diverse, well-rounded perspective on the complex dynamics of healthcare facilities.
DNV Accreditation Requirements & Categories
The requirements for accreditation through DNV are directly related to CMS’s Conditions of Participation (CoPs). They apply to any size hospital, and they’re less prescriptive than any other accrediting agencies’ standards — giving healthcare organizations the ability to prioritize initiatives for continuous improvement.
There are three categories of DNV accreditation:
- Accredited (meets corrective action plan requirements)
- Jeopardy Status (fails to meet corrective action plan requirements)
- Not Accredited
DNV Survey Process
DNV performs an on-site survey every year. The surveys are done using Tracer Methodology (per ISO 9001), staff interviews, and patient interviews. All areas of the hospital are surveyed, clinical and non-clinical. DNV surveyors are usually doctors, nurses, and specialists who must complete various training programs, 45 hours of continuing education every three years, and annual surveyor training by DNV staff.
HFAP
HFAP’s mission is to advance high-quality patient care and safety through the objective application of recognized standards. Today there are over 400 hospitals and other healthcare facilities (labs, office-based surgeries centers, etc.) that hold HFAP accreditation in the nation.
HFAP is managed by the AOA Bureau of Healthcare Facilities Accreditation, which is a panel of physicians and administrators from various specialties. Recognized as a key player in the formation of healthcare policy, HFAP is represented in all major healthcare and quality improvement forums.
HFAP Accreditation Requirements & Categories
HFAP accreditation requirements include CMS and other nationally recognized standards, as well as evidence-based best practice and patient safety initiatives. HFAP requirements exceed CMS’s CoPs and are always realistic, understandable, measurable, beneficial, and achievable for healthcare facilities.
Similar to DNV, there are three categories of HFAP accreditation:
- Full Accreditation
- Interim Accreditation
- Denial
HFAP Survey Process
HFAP performs on-site surveys of hospitals once every three years. The comprehensive, unbiased surveys focus on patient-centered processes. They also include educationally focused reviews that offer non-prescriptive recommendations for corrective action. HFAP surveyors are paid volunteers recruited from other HFAP-accredited facilities. Generally, they’re in a leadership role in their own facility and have extensive knowledge of the current healthcare industry.
Joint Commission
The Joint Commission focuses on quality care for the American public through a voluntary independent evaluation process. Its goal is to help hospitals become “high reliability” organizations for delivering safe, effective care. Around 5,000 hospitals and 10,000 other healthcare facilities are accredited or certified by The Joint Commission today.
The Joint Commission is governed by physicians, nurses, healthcare leaders, and public representatives. They work together to influence national healthcare policy, funding priorities, performance measurement, and future legislation.
The Joint Commission Accreditation Requirements & Categories
Generally, leading healthcare practice standards and National Patient Safety Goals are combined with the perspectives of healthcare professionals and key public stakeholders to form The Joint Commission’s accreditation requirements. These requirements usually exceed the CMS’s CoPs.
There are five categories of accreditation through The Joint Commission:
- Accredited (in compliance with all applicable standards, or has successfully addressed all requirements for improvement)
- Provisional (fails to successfully address all requirements for improvement within the specified timeframe)
- Conditional (nature of the requirements for improvement requires a follow-up survey)
- Preliminary Denial (severity of findings justifies denial of accreditation, but decision is subject to review and appeal)
- Denial (accreditation has been removed or denied)
The Joint Commission Survey Process
The Joint Commission performs on-site surveys once every three years. Hospitals must also perform an annual self-assessment. As far as the on-site process goes, The Joint Commission follows the Tracer Methodology (in fact, they created it!). The Joint Commission prefers this methodology because it’s patient-centered and process-focused.
All surveyors are employees of The Joint Commission and have extensive experience in healthcare. They must pass a certification exam and participate in continuous, collaborative training and education programs.
Your hospital has to comply with the standards of many different agencies and associations. Whether you’re preparing for a joint commission survey, or have a question about HFAP compliance, Vanguard Fire & Security Systems is here to help. Our team is familiar with all three accreditations and can help your hospital navigate the complex process of documentation, even if you’re making the move from one accreditation to another. Our fire protection, life safety, and security systems can all keep your healthcare facility in compliance, and our unique reporting system, Building Reports, always ensures you have the documentation you need, in the proper format. Give our team a call today, or schedule an appointment online now!
