Subpage Banner Image

Bozeman Health News

Section: Latest News

Bozeman Health Deaconess Hospital Transitioning to new Accreditation Partner


Bozeman Health Deaconess Hospital is transitioning to a new partner as an external resource for safer healthcare, providing quality‐driven accreditation and clinic excellence certifications to America’s hospitals. Here we are introducing a new way for Bozeman Health Deaconess Hospital to empower quality and patient safety; a new way to operate and perform.

Bozeman Health Deaconess Hospital is moving from the traditional Joint Commission (TJC) accreditation to a more innovative, patient‐centric accreditation crafted by DNV GL – Healthcare. Having always excelled in TJC surveys, it has become clear that passing a test every three years is not going to make us better. And it reminds us that even when we are good at what we do, we still want to look for opportunities to make us better – the DNV GL – Healthcare accreditation will do just that.


What does it mean when we say that we are “accredited”?

Just as physicians, nurses, lab techs and other staff at a hospital undergo rigorous training and testing to qualify for their work — so must a hospital as a whole demonstrate that it meets a set of quality standards. DNV GL – Healthcare is one of the independent accrediting organizations for hospitals in the

  1. that conduct these quality standard surveys.

In order to participate in government programs such as Medicare and Medicaid, Bozeman Health has to be an approved provider with the Centers for Medicare and Medicaid Services (CMS). Other insurers also use this same standard. Bozeman Health becomes an approved provider by meeting the Conditions of Participation (CoPs) required by CMS through review by a State Agency under the direction of CMS or through seeking accreditation through a CMS‐approved organization. DNV GL – Healthcare is one of these CMS‐approved organizations.

In addition to accreditation being required for Medicare and Medicaid, there are other insurers that also require the hospital to maintain accreditation.

For our patients, accreditation gives you the confidence and assurance that Bozeman Health will provide you with the highest quality care, knowing that we comply with national healthcare requirements.

Patient safety and continual, sustained improvement is our priority.

Why does it matter to Bozeman Health?

DNV GL – Healthcare combines the National Integrated Accreditation for Healthcare Organizations (NIAHO) standards with ISO 9001 (International Organization for Standardization) to impact the overall quality for the organization. These standards ensure we are taking all necessary steps to deliver safe and effective healthcare services to our patients. The National Integrated Accreditation for Healthcare Organizations (NIAHO) standards are the vehicle we use to demonstrate that Bozeman Health complies with the Conditions of Participation required by CMS.

  • ISO 9001 is a process standard — not a manufacturing standard — ideally suited to complex, people‐powered businesses. The more variables and interdependencies in your organization, the more relevant ISO becomes. As DNV GL hospitals often say, ISO provides the structure for staff to focus on common goals. Like patient care and safety. ISO puts everyone on the same page, turning individuals into teams, and teams into high‐performance enterprises. That’s why it’s called a quality management system. ISO helps you create a clear path to sustainable excellence.
  • ISO 9001 is a management system standard developed by the independent international organization, ISO (International Organization for Standardization), and is used by quality‐driven organizations in all sectors and business types.

Why does it matter to our patients?

Bozeman Health is committed to meeting – and exceeding – the highest standard for our patient’s. Compliance with CMS’s Conditions of Participation is important because those conditions are what the federal government has deemed as key to protecting patient health and safety and ensuring quality of care.

What are the benefits of accreditation with DNV GL – Healthcare?

DNV GL ‐ Healthcare brings a new approach to the accreditation process that will hold the Bozeman Health to the highest standard, and drive innovative and best practices to improve our processes.

DNV GL ‐ Healthcare presents a set of standards (NIAHO) that address the criteria imposed by CMS as well as the gradual introduction to the international standard of ISO 9001 quality management system requirements. By choosing to move forward with this dual system, Bozeman Health is being held to a much higher standard.

Providing efficient, safe, quality healthcare to those we serve is our primary objective and DNV GL ‐ Healthcare serves this objective well through their requirements and the means by which the surveys are conducted.

Why did Bozeman Health switch from Joint Commission to DNV GL accreditation?

Bozeman Health’s leadership is inspired by the philosophy of continual improvement that drove DNV GL

– Healthcare to seek to become an accreditation organization with CMS in 2008. DNV GL ‐ Healthcare was formed and proposed as an accreditation model that focused on "improvement" and "sustainability".

What difference will patients and families see at Bozeman Health facilities?

Patients should see ongoing, high quality patient care and Bozeman Health employees that are committed to continual improvement. Bozeman Health Deaconess Hospital started on the path to accreditation with DNV GL – Healthcare in the Fall of 2016.

Will this make the hospital services more expensive?

No, it should actually do the opposite. ISO focuses on efficiency of both clinical and non‐clinical processes, so if Bozeman Health can improve efficiency in non‐clinical areas as well as patient‐care areas, that should make our healthcare delivery system more affordable.

How often will an audit take place?

DNV GL – Healthcare requires annual surveys, instead of once every three years. This will ensure Bozeman Health is consistently meeting requirements while streamlining our process to be more effective in meeting the needs of our patients. This will help us improve the quality of services we provide as well as reduce costs.

Testimonials - DNV GL – Healthcare Industry Reaction

University of Utah Health Care Hospitals and Clinics – Salt Lake City, UT

“We’d been with Joint Commission for so long, everyone thought…there was only one way and that was the way it had to be done. With DNV it’s more about what works in your organization…is this going to work for you? There’s been such a culture change in our staff when it comes to surveys – I have people looking forward to having the surveyors come so that they can show them what they have accomplished in the last year and what their plans are for the coming years.” – Linda Bailey, Accreditation Specialist

Harris Health System, Houston, TX

The Harris Health System is the third largest public health system in the nation. We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs in affiliation with the Baylor College of Medicine and the University of Texas Health Science Center – Houston…We are an innovative organization and we are in full collaboration with DNV, our innovation partner. Our basic focus is to engage all 8,000+ employees in our medical staff at Harris Health, in collaboration with DNV, to improve our patient care, our processes, and the work environment. ‐ George Masi, President and CEO

“Innovation is the act of coming up with ideas and bringing them to life. Here at Harris Health Systems, our innovative approach is through our Think Innovation Program. The employee‐driven program is designed to motivate, encourage, and recognize staff with innovative ideas that: 1) improve patient care services 2) streamline processes 3) enhance the healthcare environment of patients and staff. Harris Health focuses on empowerment, organizational learning, and rewards and recognition – all levels of the organization are influenced and impact change through creative thinking. Since inception of the program, our financial impact has been over $18,000,000 (savings in the area of freight management systems, drug replacement program, GPS transportation, IT data storage, and healing arts).” – Shanna Cummings, Director, Center for Health Innovation

PeaceHealth – Washington, Alaska, Oregon

Sometimes it’s more comfortable to stick with what you know – we know how to play the game in the other accreditation world, but it wasn’t going to make us better. We were having a hard time maintaining consistency and reducing variation in the processes that were impacting our customers. If I’d gone in after or even during the surveyors from the other accreditation company, the variance in the surveys, the variance in the quality of survey, it bothered me a lot. I think that’s when we said, enough is enough, we don’t want to review 3,000+ policies a year. We need somebody to help us make sure we’re making a plan to check that.” – Margaret Beals, Director for Regulatory and Accreditation

Lee Memorial Health Systems – Fort Myers, FL

We did due diligence – we talked to other hospitals who went to DNV, we looked at ISO, we compared the standards to CMS. There’s been many things we would never have learned if it wasn’t for ISOs – obsolete procedures, obsolete diets, obsolete physician orders. DNV and ISOs pushed us into places we wouldn’t have gone without them. The learning has been tremendous and the staff knowledge of these issues has been tremendous also.” – Chris Crawford, VP Quality, Lee Memorial Health Systems

Carle Foundation Hospital – Urbana, IL

“We started with DNV in 2012 and we have been really happy with our decision to switch over to DNV. What we liked about DNV was the ISO 9001 certification process. We found it was easy to learn, easy to adopt it to a healthcare setting, our staff picked up on it easily, really liked it, ultimately reduced our costs and improving our quality and customer satisfaction.” – Lakita Travis, Accreditation Coordinator

Kootenai Medical Center – Coeur d’Alene, ID

“We needed accreditation that more closely aligned with what we were trying to do. We have a C‐Suite that’s been really committed to expanding <our organization> to meet the growing needs of our community. We did our research and we looked into what DNV offered and for us, it was a natural fit. It was one of the toughest surveys that we had ever been through, but easily the most meaningful. It’s process improvement. It’s constant process improvement. You could run a business without doing that; I think you make a lot of the same mistakes…reinventing the wheel over and over again.” – Jon Scallan, Regulatory Compliance

Westside Surgical Hospital – Houston, TX

“Their quality standards are very high. The DNV approach to surveys is about finding the best way to continually improve patient care. We all learn a lot in preparing for these surveys and in going through them. Even when you are very good at what you do, you want to look for opportunities to get even better.” – Deby Preston, Chief Nursing Officer at Westside Surgical Hospital

Categories: Employee News