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How we’ve fixed our DNV nonconformities

This summer’s surveys found areas for us to improve — which we did.


DNV-surveyFour months have passed since our last DNV survey, and work to correct identified issues has not stopped. Across the system, Asante received a total of 20 NC-2 findings, nine NC-1 findings and one NC-condition finding. These findings encompassed many areas, including:

  • Ligature risks.
  • Infection control issues.
  • Documentation opportunities.
  • Environment and life safety testing.

You might be wondering what changes were made because of these findings and how does it affect you and our patients?

Asante Rogue Regional Medical Center received a condition-level nonconformity for ligature risks in the PCU. Leaders and staff took immediate steps to mitigate and prevent potential patient harm. Longer-term strategies to ensure a safe treatment environment included upgrading to ligature-resistant furniture and fixtures and a larger-scope risk assessment of the area. In August, DNV inspected ARRMC again and cleared the condition-level finding.

Nurses in the Family Birth Centers across the system may have noticed an increased focus and education on epidural documentation for laboring patients. The birth centers at AACH and ARRMC each received nonconformities for epidural documentation not matching best practices as outlined in Care of the Obstetric Patient with Neuraxial Analgesia; Intrathecal and Epidural. Asante developed system education for all labor-trained staff and conducted internal audits of key policy elements. While work continues around this essential documentation, the audits have shown improvement.

Pain management was another documentation area identified as needing improvement at ARRMC and ATRMC. Changes in Epic are being explored, including adding documentation functionality to require and show specific pain scores based on patient criteria for all PO/IV/SUBQ/IM narcotics.

This specific functionality will allow nurses to view the last documented pain scale and document a pain and POSS assessment from the MAR administration window, creating an easier workflow. In addition to Epic changes, Asante’s standards for pain management policy was updated along with Nursing Professional Development’s pain management website.

Although ARRMC was the only hospital to receive a nonconformity related to the infection control risk posed by corrugated cardboard boxes and cardboard shipping boxes, all hospitals should note that these should not be used for storage or be in patient care areas. Efforts are ongoing to partner with Materials Management and nursing leaders to assess each unit’s current state and move items being stored in cardboard boxes into approved plastic containers.

This is just some of the work being done. We appreciate all those involved in the DNV corrective action process and every staff member who puts quality and patient safety first.

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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