Accredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. DNV draws on its wide technical and industry expertise to help companies worldwide build consumer and stakeholder trust. WebIn addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. doi:10.1017/ice.2020.295. Knowing where to focus improvement efforts is critical to take control of risk elements that can threaten your business success. 23, Sections 1-6 1-7 commission and graduated commission, What are the defects of existing curriculum, Joint commission oxygen cylinder storage 2019, DNV Managing Risk DNV corporate presentation Elzbieta BitnerGregersen, JOINT COMMISSION PANEL DISCUSSION REGARDING RECENT JOINT COMMISSION, COMPARISON AND CONTRAST COMPARISON CONTRAST Comparison points out, Aligning Accreditation and Quality The DNV Perspective The, Introduction to IDSADI 15926 Resources Ian Glendinning DNV, DNV Healthcare Top Survey Findings Medical Staff National, SOLAS requirements DNV interpretations Jan Tore Grimsrud February, Mobile Technology in Ships Inspections Thomas Mestl DNV, RBI Intro some activities at DNV Fatigue Workshop, INTRODUCING INTUMAXEP 1115 XHP DNV CERTIFICATE NO F16685, CBCD Cloned Buggy Code Detector Jingyue Li DNV, DNV a Norwegian company in Korea with focus, DNV GL studie LNG in de scheepvaart verlagen, KNEE JOINT ANKLE JOINT HIP JOINT Prof Ahmed, Shoulder Joint Shoulder Glenohumeral Joint The shoulder joint, Elbow Joint Elbow Joint Type Synovial hinge joint, SYNOVIAL JOINT Dr Iram Tassaduq SYNOVIAL JOINT Joint. All rights reserved. 0000005251 00000 n The DNV/ISO 9001 process required a lot of hard work on our part, but has provided tremendous benefits for our health system, Higginbotham. Academic & Personal: 24 hour online access, Corporate R&D Professionals: 24 hour online access, https://doi.org/10.1016/j.mnl.2009.10.004, Comparisons of the NIAHO and Joint Commission Approaches to Accreditation, Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf, Available at: http://www.dnv.com/binaries/NIAHO%20Accreditation%20Requirements-Rev%20307-8%200(2)_tcm4-347543.pdf, Available at: http://www.jointcommission.org/NR/rdonlyres/2F04C126-906D-4155-B16F-1F1A6570C387/0/jconlineAug1209.pdf, For academic or personal research use, select 'Academic and Personal', For corporate R&D use, select 'Corporate R&D Professionals', Association for periOperative Registered Nurses. The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. Findings, including non-conformities, and conclusions are presented at the end of the audit in a closing meeting and included in the audit report. SCRMC has three years from the date of its accreditation to achieve compliance with ISO 9001, the worlds most trusted quality management system used by performance-driven organizations around the world to advance their quality and sustainability objectives. DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. 4NuH.z)z06q?Rt|E"vzQV-\\-U=^4/M6z`| Y, 2mKe59\^9xg6`?,^eaQ)PHwzX=ixf#`x[aA;B|A3 $z(Gc(A%aC@)4"44SY S20L: 2("ukvVhMg9a,"J0$8 1sb s6s[fPE<1I!4XOLv^+d2(i}%C9X WebThis electronic reference tool provides plain-language interpretations of the credentialing standards for The Joint Commission, NCQA, Healthcare Facilities Accreditation Although the costs of Joint Commission and DNV are about the same, according to health experts, there are some big differences between the two: The organization surveys the hospitals that use their commissioning services annually, while the Joint Commission extends its survey periods from 18 months to three years. This electronic reference tool provides plain-language interpretations of the credentialing standards for The Joint Commission, NCQA, Healthcare Facilities Accreditation Program, DNV, URAC, the Accreditation Association for Ambulatory Health Care, as well as the Medicare Conditions of Participation. WebCommission, Healthcare Facilities Accreditation Program (HFAP) and Det Norske Veritas Healthcare, Inc. (DNV) for hospitals; gives deeming authority to NCQA for Medicare Advantage health plans Accrediting Organizations Targets for Accreditation Types of Standards Accreditation Categories NCQA Joint Commission Health plans About 200 hospitals have switched to DNV Accreditation over the past two years. Psychiatric Hospitals are accredited for a three year period, subject to annual survey to verify continuing compliance with NIAHO. Webparticipation was based on Joint Commission accreditation issued prior to that date will continue to participate in Medicare via deemed status until the normal expiration date of its accreditation. 8618 0 obj <> endobj HSMo0+TR E9dR-,Q 0000001372 00000 n We evaluate how well your management system supports your focus areas. 0000039232 00000 n Accessed April 27, 2010. Risk Based Certification is our exclusive approach to all management system certification. Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. The important role of the Joint Commission AORN J. We have taken an entirely different approach to accreditation, and hospitals are really responding, says DNV Healthcare USA Inc. President Patrick Horine. Delia Constanzo . Lesho, E., Hix, J., Bronstein, M., Shastry, S., Hanna, J., Scroggins, G., & Grieff, M. (2019). WebAddressed by TJC, Not NIAHO Verification of applicant identity Use of CVO (DNV does allow is addressed under telemedicine) Health status (DNV only under surgical As with all accreditation programs, surveyors from the organization will visit the hospital on regular annual intervals to monitor the organizations progress in implementing the new requirements. Lesho, E., Walsh, E., Gutowski, J., Reno, L., Newhart, D, Yu, S., Bress, J., Bronstein, M. A Cluster-Control Approach to a SARS-CoV-2 Outbreak on a Stroke Ward with Infection Control Considerations for Dementia and Vascular Units. WebAccredited hospitals. The Joint Commission on the Accreditation of Healthcare Organizations. Admin, South Central Family Medicine & Urgent Care, Directions to South Central Regional Medical Center, Where to Get the Best Care and When to Go. WebDNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. Through its broad experience and deep expertise, DNV advances safety and sustainable performance, sets industry benchmarks, drives innovative solutions. The report indicates if your organisation is ready to proceed with the certification audit. endstream endobj startxref The DNV accreditation program provides us the opportunity to simultaneously satisfy our Medicare accreditation requirements and implement the ISO 9001:2015 Quality Management System all at the same time, said Doug Higginbotham, Executive Director at South Central Regional Medical Center. endstream endobj 1332 0 obj <>stream More than 2,100 individuals are employed throughout health system and approximately 125 providers representing 28 medical specialties provide care to patients. The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. [fy^Mx_6vbvX,'Mqtr)yzQn.^%~&PdXfbpqxu5Y)Vwuq_DO1ou{)v]tiply/m}+s[(E}Zyc"F%x.%i%NW?VE\gcuJ[Q[Ka/.W. Accessed August 5, 2009. endstream endobj 8619 0 obj <>/Metadata 315 0 R/Outlines 731 0 R/Pages 8594 0 R/StructTreeRoot 1070 0 R/Type/Catalog>> endobj 8620 0 obj <>/ExtGState<>/Font<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 8621 0 obj <>stream In short, accreditation impacts the way hospitals operate. 0000012451 00000 n AORN Guidance Statement: Perioperative Staffing. 0000006234 00000 n Compliance is viewed as a 3-year Select from the topics below to get started. The DNV program is consistent with our long-term commitment to quality and patient safety, says Dr. Teresa Camp-Rogers, Chief Quality Officer at SCRMC. During this process, we assess your management systems degree of compliance with the requirements of the elected standard and performance in identified focus areas. % HtTKo0Wh( Grid last updated: July 2022, National Association Medical Staff Services. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. %PDF-1.6 % Our Privacy Policy | An integrated health services organization serving the people of Western New York. Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. WebOne of the large number of accreditation schemes in the United States, the Joint Commission (TJC) currently being the best known, has created Joint Commission International, or JCI. Web DNV GL Healthcare (DNV GL) The Compliance Team (TCT) The Joint Commission (JC) There are currently another seven AOs approved under CLIA, which are: American Association of Blood Banks (AABB) American Association for Laboratory Accreditation (A2LA) American Osteopathic Association (AOA) The password to view the NAMSS Comparison of Accreditation Standards is: Q7r&Km The outcome is still a certificate if the management system is found compliant but with added dimension to your improvement journey. DNV is kept apprised of the organization's level of compliance with ongoing organizational reporting. Employee Login | After each survey there is a detailed report which is easy to follow and describes, with objective evidence, where your organization is not in compliance with the standard. Country-wide, more than 5000 hospitals are permitted to provide Medicarefinanced services solely WebAccredited certification of management systems is used to demonstrate compliance to a standard in a trusted way. 0000002012 00000 n To review focus area input and agree on one to three particular focus areas upon which the audit will focus. 0000004698 00000 n Det Norske Veritas (DNV) is a global quality 0000000016 00000 n Because while undergoing the accreditation process, a hospital makes critical decisions about how it provides services, manages medications and allocates resources. 1338 0 obj <>/Filter/FlateDecode/ID[]/Index[1327 24]/Info 1326 0 R/Length 69/Prev 861584/Root 1328 0 R/Size 1351/Type/XRef/W[1 2 1]>>stream 1327 0 obj <> endobj In case of expanding the scope the process will restart at section 2 with a documentation review (if needed) and will further follow the normal process from section 4 with a (scope extension) certification audit. The documentation review can be performed prior to or conducted as part of the initial visit. All rights reserved. By earning accreditation, SCRMC has demonstrated it meets or exceeds patient safety standards (Conditions of Participation) set forth by the U.S. Centers for Medicare and Medicaid Services. Innovative hospitals have started embracing ISO as a way to identify and focus on the most successful approaches to patient care, billing and other critical aspects of running a modern hospital system. Provides a framework for organizational structure and management Accreditation involves preparing for a survey and maintaining a high level of quality and compliance with the latest standards. Joint Commission accreditation provides guidance to an organizations quality improvement efforts. At Newark-Wayne, Rochester General Hospital, United Memorial and Unity Hospital. LAUREL, MS, South Central Regional Medical Center (SCRMC) announces the successful completion of its new accreditation process that has been awarded by DNV. %PDF-1.6 % The International Standards Organization (ISO) Web site. At this stage you have completed the initial certification and can move on to maintenance of your certification. 2019 HIMSS Annual Conference: Clinical Optimization: One Approach to Integration, 2019 Breakthroughs Conference: Clinical Optimization: A Panel Discussion. 0 n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. 0000013305 00000 n We use cookies to help provide and enhance our service and tailor content. org 22, Questions to Consider Will our reputation in the community suffer if we change? 120 0 obj Hospital Mater Dei. Infection Control & Hospital Epidemiology. See upcoming training courses. DNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. Medical Student H&P | Project Director, CHC Accreditation . %%EOF South Central Regional Medical Center has been Joint Commission accredited for years and hospital personnel are very familiar with the accreditation process, but Joint Commission does not require ISO certification. Vendor Login | Centers for Medicare and Medicaid Services. 0000002975 00000 n WebWe have a variety of resources to help you explore and master the accreditation process. The documentation review report summarizes any findings from this process. The scope of certification is agreed at an early stage in the certification process. Accreditation Canada accredited its first organization internationally in 1967 in Bermuda. DNVs philosophy is to assist Psychiatric Hospitals through compliance with the NIAHO Hospital Accreditation Program and Appendix B standards, encouraging a safe and therapeutic milieu which allows patients to be treated safely and effectively. We have to get a clear understanding of your business strategy and conditions that affect your ability to reach said strategy. When found compliant, we issue the certificate. WebAssistant Director - Accreditation Services . At Rochester Regional Health, our dedication to quality is reflected in the teams we hire, the care we provide and the services we offer. Hover over the "Register" button in the top right corner to see the price, 1 Question|Unlimited attempts|1/1 points to pass|Graded as Pass/Fail. hbbd``b` @)H0A@"*HpE$> oL,F6~0 d Therefore, accredited certification consists of a 3-step cycle: To tailor the audit, we need to know what is important to your organisation. Below are several components of our psychiatric hospital accreditation program. Lab Specimen Guideline | This is the authorities way of auditing the auditors, such as certification bodies like DNV. Because there would be a time gap between Joint Commission and DNV accreditation, Rosen worked with the state Department of Health and the local CMS DNV conducts a survey every year instead of every three years. After the three years are up, your certification will be extended through a re-certification audit. In addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. Based on a positive outcome, he/she will recommend certification. DNV Healthcares hospital accreditation program is unique in that it integrates the ISO 9001 standards (international quality standards that define `0 d``_}C!\ |S0\`0[znV$5*c"00z`PwzS\u@_w{wSZ3@`|4iE"'-*5wIsr]gI qyO'WAm)U1Ys96S=ffXTjMJ5P)TTOVyN9xddiV,ey-E% 0000007824 00000 n By 1991, TJC had learned that it was not possible to ensure quality and had moved on to quality improvement and its many iterations, now known as performance improvement. <>stream DNV Healthcare, Joint Commission emphasize differences. Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? Before the audit starts, you provide input on what operational processes are most crucial to your business success. PMID: 12085409 Joint Commission on Accreditation of Healthcare Organizations* / history 0000003418 00000 n H\J@{6fgBA[^Hi M}{voI\]fcuvO1}yPYq:\xvwm,.rsi`at3Xvizx)vnn. The decision to grant initial certification, renew certification or to expand or reduce the scope of certification, is made by competent and authorized personnel in DNV who are different from those carrying out the audit. 0000001631 00000 n <>/Pages 117 0 R /StructTreeRoot 177 0 R /ViewerPreferences<>/PageLayout/OneColumn/Type/Catalog/MarkInfo<>/Lang( E N - U S)/Metadata 262 0 R >> There is always an opportunity to improve. WebDNV offers a number of standards - Hospital Accreditation, Stroke Center, Orthopedic Service Line, Infection Risk and more. WebThis background is fascinating in view of The Joint Commissions (TJC) history. Infection Control & Hospital Epidemiology (2020), 41, 13441347. TCI certification. WebAccreditation and certification are important accomplishments and we are here to help your organization throughout the entire process. 630-792-5509 | rzordan@jointcommission.org. Joint Commission Online, August 12, 2009. As DNV hospitals often say, ISO provides the structure for the staff to focus on 0000000913 00000 n *This product is a downloadable document and does not ship. H|S[o0~WL3CJ)d[+ej8["ChT(/>| Lr= 1A/?7_]"`WW0 MB%pf4{R)"~"LeC$X8 V+I::'p8%I^H$pfr>8hY6/Fd&JA#aNj,'{?li1z\) Since accreditation is a must-have credential for just about every hospital in this country, why not make it more valuable, and get more out of it? Search our services and programs offered by our experts at our hundreds of locations throughout Western New York and the Finger Lakes region. Accreditation | It is widely recognized as the gold standard in healthcare accreditation, and its standards are considered rigorous and comprehensive. Subsequently 1-3 focus areas on which the audit will focus are identified. 0000020794 00000 n Learn About Accreditation Survey Why? Top management should be involved at this stage. Our lead auditor will verify that you have properly addressed the nonconformities. Find the location that's most convenient for you! Infection Control & Hospital Epidemiology,40(9), 1066-1069. doi:10.1017/ice.2019.164. Biocor Hospital De Doencas Cardiovasculares LTDA. In 2020, Rochester Regional Health participated in 123 regulatory surveys in our acute care settings, outpatient settings and specialty programs from compliance agencies like DNV Healthcare, The Joint Commission and the Department of Health. xb```f``ue` ea *(ltSa{+ 9QQ (MHKX*?6Y ,8v'83rXrE0C;;[70^} Ua vHCO4@ZT Dr g$ The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. Thats where ISO 9001 comes into play and turns the typical get-your-ticket-punched accreditation exercise into a quality transformation.. endstream endobj 138 0 obj <>stream ISO is the International Organization for Standardization. These surveys, often routine or planned to certify our specialty programs, look at our communication processes, governance, processes, standardization, safety precautions and outcomes. endstream endobj 1331 0 obj <>stream David Eickemeyer, MBA; Associate Director, Hospital Business Development. SOUTH CENTRAL REGIONAL MEDICAL CENTER RECEIVES QUALITY-BASED ACCREDITATION FROM DNV. Both your management system and certificate have to be maintained. This is a list of the hospitals accredited to the international standard by DNV. 127 30 I*Rt>[?Yim*>"1t>hvYJa`h0vh` 2+@,F0)fP`c6e,ITWhLVJCXLFu @B@h6{E@E"% @lT- g Hu.5LL00~gPdpMej8 PClY~p=Tt n`xH108Y * ~ D\z Comparison of The Joint Commission and DNV- GL HCs National Integrated Accreditation for Healthcare Organizations (NIAHO) MS Standards Kathy Matzka, CPMSM, CPCS 1, History TJC 1952 began Unique statutory hospital deeming authority 1965 Medicare statute July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 became law 11/09 CMS approval 4, 546 Hospital and CAH in 2011 4, 429 Hospital and CAH in 2013 (90% of accredited hospitals) 4, 032 Hospital and CAH in 2016 (88% of accredited hospitals) NIAHO 12/19/07 Application to CMS 09/08 CMS approval 94 Hospital and CAH on 7/14/10 393 Hospital and CAH on 4/17/2016 2, Process TJC NIAHO Three year survey Annual Survey Standards directly Most MS standards related to the CMS as directly related to the well as self-defined CMS ISO 9001 quality management 3, Scoring Process TJC NIAHO Three-point scale: 0 = insufficient compliance 1 = partial compliance 2 = satisfactory compliance Icons Documentation required Situational decision rules apply Direct impact requirements apply Category A requirement Category C requirement (based on # of times does not meet standard) Measurement of Success needed Standards Scored as Meets requirements Nonconformity Category I Conditional level Egregious non-compliance Nonconformity Category I Noncompliant Nonconformity Category II Occasional or isolated lapse in compliance Immediate Jeopardy Immediate threat to patient safety No aggregate scoring 4, Appointment Timeframe TJC Two years NIAHO Three years if state law does not address 5, Continuing Medical Education TJC NIAHO LIPs and other practitioners All with privileges participate in privileged through the medical CE that is at least in part staff process must participate related to their clinical in CE privileges Participation must be CME considered in decisions documented and considered in about reappointment or decisions about reappointment, renewal or revision of clinical renewal, or revision of privileges individual clinical privileges Action on an individuals application for appointment /reappointment or initial or subsequent clinical privileges is withheld until the information is available and verified 6, Current Competence TJC The hospital verifies in writing and from the primary source, whenever feasible, or from a CVO, information concerning the current competence Evaluate data from other organizations where the applicant currently has privileges, if available NIAHO Initial - MS qualifications include verification of current competence Reap - Review of individual performance data for variation from benchmark Variations to peer review for determination of validity, written explanation of findings and, if appropriate, an action plan to include improvement strategies 7, Malpractice History TJC NIAHO MS evaluates Review of involvement in a any professional liability action at initial and action, including final reappointment judgments and settlements involving a practitioner Must evaluate any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant 8, Peer Recommendations TJC NIAHO Required at initial, reap, consideration of termination, or revision/revocation of clinical privileges Address the relevant training and experience, current competence, and any effects of health status on privileges being requested Include evaluation of the applicants medical knowledge, technical and clinical skills, clinical judgment, communication skills, interpersonal skills, and professionalism Obtained from a practitioner in the same professional discipline as the applicant with personal knowledge of the applicants ability to practice List of appropriate sources Two peer recommendations required at initial appointment 9, Clinical Privileges TJC NIAHO PSV for current licensure or All permitted by the certification organization and by law to PSV of relevant training provide patient care services Evidence of physical ability to independently have delineated perform the requested privilege clinical privileges If available, data from If available and/or required by professional practice review the MS, a review of individual from other organization where performance data variation the applicant currently has from criteria determined by the privileges medical staff to identify need Recommendations from for training or proctoring that peers/faculty may be required On renewal, review of the applicants performance within the hospital 10, Telemedicine TJC NIAHO 3 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing information from the distant site if the distant site is a Joint Commission-accredited organization or Use credentialing and privileging decision from the Joint Commission-accredited distant site Medical staff at both sites make recommendation for services to be provided via telemedicine For non-deeming, can be via contract only if TJC accredited entity 2 choices The originating site can fully privilege and credential the practitioner according to MS standards or Use credentialing and privileging decision from telemedicine entity or distant site Medicare participating hospital When services provided by a contracted entity, GB must identify criteria for selection and procurement of services and how to evaluate the entity 11, Temporary Privileges TJC NIAHO 120 days for new applicant with complete file awaiting MEC approval Time as specified in bylaws for patient care need On recommendation of MS President or designee No successful challenges to licensure or registration; involuntary termination of MS appointment; involuntary limitation, reduction, denial, or loss of clinical privileges Not exceed 120 days Locum tenens not to exceed 6 months On recommendation of a MEC member, MS president or medical director (as defined by MS Urgent patient care need Complete application w/o negative or adverse information before action by the medical staff or governing body 12, Temporary Privileges TJC NIAHO Patient care need verify Current licensure Current competence New Applicant verify Current licensure Relevant training or experience Current competence Ability to perform the privileges requested Other criteria required by medical staff bylaws NPDB In all cases verify education (AMA/AOA Profile OK current competence primary verification of State professional licenses professional references (including current competence) Database profiles from AMA, AOA, NPDB, and OIG Medicare/Medicaid Exclusions 13, Allied Health Professionals TJC NIAHO LIPs through MS process Non-LIP APRNs and PAs HR or MS if not providing a medical level of care If State law allows, MS may include DPM, OD, DC, PA, CRNA, NM, APRN, DMD, PHD or other designated professionals approved by MS and Board and eligible for appointment 14, Executive Committee TJC NIAHO 10 EPs outlining responsibilities, structure, function If MS has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy CEO and the nurse executive of the organization or designee shall attend each meeting on an ex-officio basis, with or without vote 15, TJC Notifications NIAHO The decision to grant, A current roster listing deny, revise, or each practitioners revoke privilege(s) is specific surgical disseminated and privileges must be made available to all available in the appropriate internal surgical suite and external persons scheduling area or entities, as defined Include surgeons with by the hospital and suspended surgical applicable law privileges or whose surgical privileges have been restricted 16, Surgical Privileges TJC NIAHO Included in general category for privileges All practitioners performing surgery have surgical privileges established by the department of surgery and medical staff and approved by the governing body Privileges for general surgery and surgical subspecialties defined with established criteria approved by MS Privileges correspond with established competencies of each practitioner 17, Automatic Suspension TJC NIAHO The medical staff bylaws include description of indications for automatic suspension or summary suspension of a practitioners medical staff membership or clinical privileges description of when automatic suspension or summary suspension procedures are implemented The medical staff will define the criteria and have a mechanism for consideration of automatic suspension of clinical privileges of a practitioner at a minimum when: revocation/restriction of professional license DEA certificate has been revoked, suspended or on probation Failure to maintain the minimum specified amount of professional liability insurance non-compliance with written medical record delinquency or deficiency requirements Mechanism for immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioners Medicare or Medicaid status 18, QA/PI Data TJC FPPE OPPE Medical Assessment Blood Medication Operative and other procedure(s) Appropriateness of clinical practice patterns Significant departures from established patterns of clinical practice Use of criteria for autopsies Sentinel event data Patient safety data NIAHO Practitioner specific performance data is required and must be ratebased with comparative peer or national data available for comparison.
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