DNV visits to Ashland, Grants Pass hospitals yield findings

Despite the challenges you faced over the course of the pandemic, you kept patient safety and quality at the top of your priorities. This was apparent during our recent DNV accreditation surveys at ATRMC and AACH. While some nonconformities were found, the surveyors were impressed by our dedication and commitment to deliver care and lead our community’s efforts to combat COVID-19.

For many of you, this may have been your first time experiencing an on-site DNV survey. You may have realized, while DNV is here to ensure we are following our processes and providing safe care to our patients, they are interested in hearing about your efforts.

DNV has three levels of nonconformity findings, shown in the accompanying column. I am pleased to share that neither AACH nor ATRMC had any of the more serious condition-level findings. All but one of the nonconformities identified in 2020 were closed at AACH and all but two were closed at ATRMC. Thank you for your diligent efforts to correct these areas. Here’s how each hospital did:

Asante Ashland Community Hospital

Seven NC-2 findings:

• Internal audit. This nonconformity remains open from the 2020 survey, and patient grievance processes.
• Annual review of the effectiveness of the pain-management system.
• Sterile instruments and supplies being stored outside a sterile environment.
• Life-safety management inspection and testing frequency.
• Testing frequency for eyewash and drench shower and security of electrical panels.
• Expired preventive maintenance for medical equipment.
• Physical environment risk assessments and calibration of facilities equipment.

Two NC-1 findings:

• Documentation of maternal and fetal assessments while epidural is in use and documentation of removal of the epidural catheter.
• Availability and training of malignant hyperthermia rescue materials.

Asante Three Rivers Medical Center

Eight NC-2 findings:

• Internal audit. This nonconformity remains open from the 2020 survey, and patient grievance processes.
• Annual review of the effectiveness of the pain-management system.
• Informed consent documentation.
• Restraint documentation.
• Risk assessment for dedicated ligature risk rooms.
• Height of mounted fire extinguishers and life-safety management inspection and testing frequency.
• Missing elements from the annual security vulnerability assessment.
• Expired preventive maintenance for medical equipment.

Two NC-1 findings:

• Approval of the operating room wet/dry risk assessment. This nonconformity remains open from the 2020 survey and is escalated to an NC-1.
• Soiled utility room in positive-pressure and physical environment risk assessments and calibration of facilities equipment.

Noteworthy efforts at Asante Ashland Community Hospital and Asante Three Rivers Medical Center:

• Efforts to tailor services to patient demographics (age-friendly and baby-friendly).
• Departmental quality and employee initiatives; personalization on the units.
• COVID response, including redeployment of staff during the pandemic to help cover critical functions and areas, quick ability to accommodate and retrofit surge locations; ED triage process.
• Multidisciplinary effort to help prevent escalation of patient behavior.
• Newly renovated spaces.

DNV is anticipated to survey ARRMC in June. As a reminder, departments should be completing priority rounding logs weekly to help prepare for the upcoming survey.

Nonconformity key

NC-Level 2: There is an established process with an opportunity to ensure greater consistency.

NC-Level 1: There is no process or there is a significant variation in how the process is followed.

NC-Condition: There is a broken process with a patient-safety component.