DNV results are in — how did we do?

Congratulations to everyone for a spectacular 2020 virtual DNV survey. Thank you to staff, leadership and providers across the health system.  A special thank you to Jamie Wagner and Sheldon Cowger, our Epic experts for guiding the surveyors through the electronic health record system.

We did have a few nonconformities. You’ll will be thrilled to know none of them happened to be a dirty refrigerator. Let’s define what a nonconformity is. DNV has three levels of nonconformity findings. Level 2 nonconformity means there is an established process, but there is opportunity to ensure consistency of following process. Level 1 nonconformity means there is no process or there is a significant variation in the process being followed. Condition Level-NC are nonconformities where there is a broken process with a patient safety component.

Here’s how each hospital did:

Asante Ashland Community Hospital

All 2019 nonconformities closed.

2020 findings

Three NC2 findings:

• Internal audits
• OR receptacle testing
• Generator load bank testing

Three NC1 findings:

• Restraints or seclusion
• Informed consent
• Life safety management inspections including: monthly kitchen hood, monthly gauges on pipe sprinkler systems and monthly control valves

Noteworthy efforts:

• Cleanliness of hospital
• Pride of staff
• COVID-19 compassion kits
• Pharmacy after-hours process

Asante Three Rivers Medical Center

All 2019 nonconformities closed.

2020 findings

Four NC2 findings:

• Informed consents
• Internal audits
• OR receptacle testing
• Life safety management inspections including: monthly kitchen hood

One NC1 Conditional Level finding:

• Immediate-use steam sterilization (IUSS)

Noteworthy efforts:

• Cleanliness of hospital
• Pride of staff
• Pharmacy after-hours process

Asante Rogue Regional Medical Center

All 2019 nonconformities closed.

2020 findings

Three NC2 findings:

• Medical equipment management, asset tags and approval of vendor devices
• Internal audits
• OR receptacle testing

One NC1 finding:

• Life safety management inspections, including: monthly kitchen hood, monthly gauges on pipe sprinkler systems, monthly control valves and annual fire exit drill

Noteworthy efforts:

• Medication management with bedside delivery
• Monitoring of grievances
• Decrease rate of IUSS, action taken and adequate documentation
• OB-ED department
• Maternal Fetal Medicine outreach and telemedicine