This past week, Centers for Medicare and Medicaid Services  (CMS) identified 758 hospitals that have high rates of patient safety issues. As a result, their 2016 Medicare reimbursements are being reduced by 1%. This is the second year for this federal mandate and there are over 400 (over 50%) repeat hospitals. The CMS program is entitled “Hospital-Acquired Condition Reduction Program”. The name alone is very telling.

My guess is that the intention of this 1% penalty, a sustainable benefit from the “hospital-acquired condition reduction” program will not be fully realized. A 2007 study revealed that speeding tickets are ineffective in reducing speeding. The only real benefit is to the government coffers that collect the fines.

There is, however, new anecdotal evidence that our patient safety efforts that began in the late 90’s are beginning to help us show improvement. The problem still remains that as healthcare professionals, we are not taking full advantage of existing programs to help us make a safer patient environment.

Understanding and fully implementing ISO 9001:2015 as a requirement of your DNVGL accreditation can create real value and can drive patient safety. Let’s briefly review some of the main requirements of ISO 9001 to validate this statement:

• Context of the organization- This reflects the leaderships focus and sets the tone for the entire management system.
• Enhanced process approach required by ISO 9001:2015- The writers of this newest revision added these enhancements by design. The previous version of ISO 9001 got us thinking and working on our process management, think sequence and interaction. This new 2015 version requires a deeper perspective of managing our processes, their outcomes, ensuring resources for the processes and introduces the new concept of risk-based thinking, noted as addressing risk and opportunities.
• New concept of risk-based thinking- The ISO writers state that risk-based thinking is in every chapter of the 2015 version. When a hospital can maximize process management and risk-based thinking, they are on their way to creating a safer patient environment. When process and risk are effectively integrated, the results are synergistic.
• New requirements for leadership. The term now used to describe leadership is “engagement”. Leadership also has to integrate the quality management system with the hospitals strategic direction and business processes. This circles back to the context of the organization. If the “tone at the top” is engaging, then optimizing the system will become a cultural asset.

ISO 9001 is one portion of DNVGL’s accreditation. NIAHO (National Integrated Accreditation for Healthcare Organizations) is the other portion. If a hospital can optimize the requirements of ISO 9001 and fully integrate the NIAHO standards, the results are an efficient management system that produces a safer environment for your patients. Your accreditation (that you are already paying for) CAN be an asset on your balance sheet, not a liability. The choice is yours. We know that hospitals cannot afford to pass along hospital-acquired conditions to your patients. That choice is yours too!

Bio:

Ted Schmidt is a Pharmacist, a Certified Enterprise Risk Manager (CERM©), and a Senior Advisor with BlueSynergy Associates, LLC. BlueSynergy Associates maximize innovation, experience and customer perspective to reduce risk and make hospitals a safer environment. He currently advises and instructs hospitals in quality, risk, safety and environmental management systems. Ted led the largest ISO 9001 implementation in healthcare at the Veterans Administration. He is a Senior Member of the American Society for Quality and a certified Lead Auditor in quality management systems by Exemplar Global. He can be reached by email at tschmidt@bluesynergyassociates.com.