Clinical Care

DNV is coming — are we prepared?

Read and download a checklist of what surveyors look for.


DNV-GL Healthcare, our accreditation organization, may conduct surveys at Asante as early as April 19. You don’t need to be a clinician to ensure we’re ready for surveyors. It’s a team effort! Here are a few things some or all employees should know:

Fire safety
  • Understand the initials RACER (rescue, alarm, confine, extinguish, relocate) and PASS (pull pin, aim, squeeze and sweep). Policy: Asante Code Red Fire Response Plan 400-PE-0001.
  • Know the location of fire alarm pull stations. Remember, in case of a fire you must pull the alarm and dial 4444 at AACH or 777 at ARRMC and ATRMC).
  • Know where the fire extinguishers are in your workspace.
  • Know the location of smoke compartments.
Environmental assessment
  • Locate your nearest eye-wash station.
  • Know how to access the MSDS for hazardous chemicals.
  • Keep fluid warmers within correct temperature range of 95 to 104 degrees F. Policy: Blanket and Fluid Warmer 400-PE-0502.
  • Fluid should be stored only in fluid warmers, not in blanket warmers.
  • Blanket warmers should not exceed 140 degrees F. Blanket and Fluid Warmer 400-PE0502.
  • The environment should be clean (free of food delivery carts, etc.) and uncluttered.
  • Equipment must not block fire exits, corridor fire doors, fire extinguishers or fire alarm pull stations.
  • Hallways should be clear of beds or equipment, including mobile computer carts not in use.
  • Oxygen tanks should be secured and never stored on wheelchairs.
  • No clean items should be stored in dirty utility rooms; no flower vases are to be kept or stored.
  • Food and drink must be correctly labeled and stored in designated areas. Staff food should be labeled and stored only in staff refrigerators. Patient food should be stored only in patient-labeled refrigerators.
  • Understand the process for sequestration and reporting of medical device issues. Policy: Medical Device Tracking and Reporting 400-PE-0400.
  • The clearance from the top of shelves or stacked items to the ceiling must be at least 18 inches.
Infection prevention
  • All employees must practice hand hygiene as appropriate.
  • Special precautions should be fully implemented and followed.
  • Staff must follow enteric precautions when indicated for difficile infection.
  • Tape should not be used on medical equipment or furniture.
  • No items should be stored under sinks.
  • Only non-refillable ultrasound gel containers are used for sterile procedures.
  • Inspect high-risk/low-utilization carts and areas for outdates.
  • Equipment must be wiped down between each patient.
Document control
  • Do not copy or use copies of documents. Always visit myAsanteNET for current documents.
  • Documents posted in the department must be current and controlled.
  • Reference manuals must have “for reference only” on the book or binder and used for reference only, not as current information.

To learn more, visit the accreditation page on myAsanteNET.

Download and post this checklist

Tags: accreditation, checklist, DNV, Holly Nickerson, STAT, surveyors
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If you have a question, please contact the author or relevant department directly.

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