The newest hospital accreditation option is National Integrated Accreditation for Healthcare Organizations (NIAHO), developed by DNV Healthcare, an operating company of Norway’s Det Norske Veritas (DNV). So far, approximately 160 hospitals have pursued NIAHO accreditation. Because this option is relatively new, little has been written about it. Thus, it should be noted that much of the information for this article comes directly from DNV.

DNV Healthcare was granted deeming authority by CMS in 2008. Any hospital accredited by DNV after that date is deemed to be in compliance with CMS Conditions of Participation (CoPs). It should be noted, however, that receiving accreditation from an organization with deemed authority does not prevent any hospital from undergoing survey by CMS or state Departments of Health.

The Standards
DNV’s NIAHO standards take into account the CoPs, and merge them with the ISO 9001 Standard for the formation and implementation of quality management systems. The ISO 9001 Standard was first published in 1987 and was revised in 2008 to address the issues faced by facilities in service industries, including healthcare. ISO changes the standards no more frequently than every six years.

Changes to the NIAHO standards can be broken down into two groups: mandatory and discretionary. Mandatory changes occur when NIAHO standards are altered to conform to a change in the CMS CoPs. Discretionary changes, on the other hand, clarify existing standards or incorporate practices and principles to enhance the NIAHO accreditation program. Such changes occur through a thorough review process, involving input from the field and applicable agencies and review by DNV’s accreditation management team.

The Survey Process
Similar to the processes of CMS, as well as The Joint Commission and other accrediting organizations, NIAHO surveys are conducted through tracer methodology, in combination with staff and patient interviews. While surveying the hospital to the CoP criteria, DNV surveyors also ensure that hospitals are compliant with the ISO 9001 standard, throughout both clinical and non-clinical areas.

Surveys are conducted by at least two surveyors—a physician or registered nurse and a physical environment specialist. A generalist will be added to the surveyor complement for larger hospitals. For hospital systems, the number and mix of surveyors depends on how the system has structured its quality management system. If the hospital system adopts a single approach to quality management across its facilities, the number or surveyors and survey days is minimized.

DNV accreditation decisions are not determined by the number of survey findings. In other words, there is no “magic number” of findings that will cause a hospital to be denied accreditation. Rather, after survey, hospitals receive a preliminary report from the survey team, followed within ten days by a final report. The hospital will then have ten days to submit a Corrective Action Plan with timelines for implementation to address any citations. Upon approval of the plan, DNV’s Accreditation Committee makes a final accreditation decision, and the hospital’s accreditation goes into effect on the last day of the survey.

It should also be noted that hospitals can gain NIAHO accreditation without being fully compliant with ISO 9001 standards at the time of survey. In fact, hospitals have three years in which to achieve compliance. DNV believes hospitals that have already obtained accreditation through another regulatory body, or have passed a CMS or state survey, are already well on their way to 1SO 9001 compliance. Full compliance is assured through a series of annual surveys that roughly follow this timeline:

• Year 1 – NIAHO Accreditation and Introduction to ISO 9001
• Year 2 – NIAHO Accreditation and ISO 9001 Pre-assessment Survey (Much like a mock survey, the pre-assessment survey measures readiness and identifies any gaps in compliance.)
• Year 3 – NIAHO Accreditation and Stage 1 ISO 9001 Surveys (to confirm hospital readiness for an ISO 9001 Compliance/Certification Audit)
• Year 4 – NIAHO Accreditation and ISO 9001 Compliance/Certification Audit
• Years 5 – NIAHO Accreditation and ISO 9001 periodic audit
• Year 6 – NIAHO Accreditation and ISO 9001 periodic audit

Benefits
The extended timeline for achieving full ISO 9001 compliance seems to be one of NIAHO accreditation’s primary benefits. Since hospitals are given leeway to achieve compliance over time, they can avoid the rush to correct deficiencies that often accompanies other accreditation processes.

Another potential benefit of the NIAHO accreditation process is its flexibility with regard to clinical standards. DNV’s philosophy does not dismiss the notion that patient safety goals can be effective. However, they also believe hospitals should develop individualized programs to address patient safety in their facilities. Thus, NIAHO accreditation merely requires hospitals to be accountable to ensure that quality management processes are planned, managed, measured, documented and improved.

Costs
Costs of NIAHO accreditation fall into two general categories: preparation costs and survey costs. Preparation costs derive mainly from standards manuals and human resources necessary for achieving readiness. NIAHO℠ Standards, Interpretive Guidelines, and Accreditation Process can all be downloaded for no charge at www.dnvaccreditation.com. Similarly, the ISO 9001standards can be purchased at www.iso.org or www.asq.com. Since the NIAHO survey process involves yearly, on-site surveys to encourage readiness, DNV argues that hospitals will be able to avoid the “ramp-up” costs normally associated with other forms of accreditation. The thinking here is that more surveys lead to a better understanding of organizational readiness, and therefore fewer surprises and less need to quickly assign resources to address concerns.

In addition, DNV claims that there are no indirect costs associated with NIAHO accreditation. In fact, their literature cites, by way of contrast, the model of Joint Commission Resources, affiliated with The Joint Commission, which sells consulting and publications to hospitals to help them prepare and maintain Joint Commission standards. However, this model does not appear to be vastly different from DVN’s own operation. DNV offers various free training resources, including 90-minute webinars. However, the company also provides, at a cost, day- and week-long training programs, on-site programs for individual organizations, and personal training and updates for one person at any given hospital. These may, in fact, be considered indirect preparation costs.

Survey costs, as quoted by DNV, include all fees and expenses and are based on the number of surveyors and the length of the survey, which are usually determined based on the following factors:

• Size of the facility, based on average daily census and number of FTEs
• Complexity of services offered, including outpatient services
• Type of survey to be conducted
• Presence of special care units or off-site locations, and the distance from the main campus

All in all, NIAHO accreditation by DNV provided a compelling option for hospitals seeking flexibility in meeting compliance standards and that may already have an inclination toward more industrial approaches to ensuring quality. More information about NIAHO accreditation can be found at www.dnvaccreditation.com. And you can follow the other installments of our “Accreditation Choices” series.