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Accreditation is regarded
as one of the key measures of an organization's success and
commitment to quality. During surveys, teams from the
accrediting body visit various areas of health system and, based
on a specific set of criteria, evaluate strengths and identify
opportunities for improvement. External accreditation helps
reinforce to our patients and the community that we continually
strive to offer the best possible care.
Lee Memorial Health System
has participated in the accreditation process through The Joint
Commission, or TJC, for several years. TJC is a non-profit
organization that certifies and accredits more than 17,000
hospitals throughout the nation.
In fact, LMHS has received
special certification from TJC for several of our programs,
including Orthopedics, Cardiac, Stroke and Diabetes.
However, last fall the Lee
Memorial Health System Board of Directors supported a
well-researched recommendation to pursue system accreditation
from Det Norske Veritas for Health Care, or DNVHC, concurrently
with accreditation from The Joint Commission, or TJC.
DNVHC is the first
accrediting body, in addition to TJC, in about 40 years to meet
the Conditions of Participation by CMS for survey requirements.
DNVHC received the approval to become an accrediting agency in
September 2008.
Review by an accrediting
body, such as DNVHC, is voluntary for hospitals. However, the
accreditation can serve dual purposes: it can fulfill the survey
requirements of CMS to receive Medicare and Medicaid
reimbursement, rather than a state-conducted survey, and it can
help the health system establish and promote its quality of care
standards. Additionally, many educational programs and other
services essential to operating a health system do require
external accreditation.
DNVHC is unique from TJC in
several ways, and we believe these aspects will be beneficial to
our health system. For instance, DNVHC has integrated the
Conditions of Participation regulations, or NIAHO standards,
with a quality management system, ISO-9001. This is an
innovative approach that will be a clearer gauge as to the
quality of our programs. Also, this accrediting agency requires
annual surveys, as opposed to a survey every three years.
Finally, DNVHC has said they will try to use the same survey
team during the annual surveys to assist our teams on our
continuum of improvement. We believe these elements will provide
us with a thorough and consistent accreditation process.
LMHS could be surveyed by
DNVHC as early as May of this year. We have already begun
preparations for our initial survey, including staff education
and leadership training.
This will be an exciting
time for our health system, as we look even farther to ensure
that we truly are providing the best possible care for our
patients.
Peace,
Jim Nathan
President, Lee Memorial Health System
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