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February’s DNV survey found nonconformities — we’re fixing them

Work is underway to correct the NC-1 and NC-2 findings in time for the next regularly scheduled survey.


In February, Asante completed one of two DNV accreditation surveys for 2023. Although it was a virtual survey, it did not stop DNV from noticing the improvements made across the organization, which helped to close nearly all open nonconformities from an earlier survey.

Asante closed 28 out of the 30 open nonconformities across the system. This is a testament to your focus on patient safety and quality. The two nonconformities that remain open are informed consent documentation and restraint documentation. Both of which demonstrated ongoing corrective action, but due to the timing of the survey were not complete.

In addition to the informed consent and restraint documentation nonconformities, Asante received eight new nonconformities.

NC-1 NC-2
AACH MM.1, MM.4 Titration. Medication protocol does not provide guidance and parameters for the titration amounts and frequency. PR.5, SS.4 Informed Consent Documentation. Informed consent forms did not contain a witness signature.
PE.4 Security Management. Missing security officer required NFPA99 training element for fire watch.
PE.8 Utility Management. Soiled utility rooms not negative-pressure compared with public corridors.
ARRMC PE.2 Life Safety Management. Missing or improper signage for the medical gas manifold room; incorrect load voltage testing frequency for the fire alarm systems; no routine testing of the sprinkler gauge system.
ATRMC PE.2 Life Safety Management. Monthly sprinkler gauge inspection and annual battery load voltage testing.
PE.5 Hazmat Management. Non-hospital staff authorizing manifests.
PE.8 Utility Management. Emergency generator battery not tested monthly.

While the surveys happened just over a month ago, corrective actions are well underway. Our Facilities teams across the organization have completed nearly all physical environment corrective actions.

A multidisciplinary team that includes Pharmacy, Risk Management, Critical Care and Nursing Professional Development was established to work through the corrective action plan for the medication-management nonconformity. This includes updates to titration protocols and linking to protocols in Epic.

Additional work around informed consent, including updates to the policy and consent form, are underway. These changes will better align with current practice, provide clarity on required documentation and eliminate unnecessary elements from the consent form.

Lastly, corrective actions continue around restraint documentation, including Epic documentation optimizations and policy revisions. Additional information around informed consent and restraint documentation will be available when the corrective actions have been finalized and are ready to be implemented.

Asante will undergo another periodic survey late summer or early fall as normal survey cadence resumes.

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.

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