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DNV results are in — how did we do?

Surveyors did find some nonconformities that each hospital will need to address.

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The accreditation team with their virtual surveyor, from left: Melissa Bellm, RN; Ken Lewis; Sam McHenry; Betty Gaeden, RN; Anna Spellman, RN; Clarissa Larsen, RN; and Kim Sevey, RN. Not pictured: fearless leader Holly Nickerson.

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
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