Below are several components of our psychiatric hospital accreditation program. About South Central Regional Medical Center. We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. In short, accreditation impacts the way hospitals operate. 2023 Rochester Regional Health. <>/Pages 117 0 R /StructTreeRoot 177 0 R /ViewerPreferences<>/PageLayout/OneColumn/Type/Catalog/MarkInfo<>/Lang( E N - U S)/Metadata 262 0 R >> DNV Healthcares hospital accreditation program is unique in that it integrates the ISO 9001 standards (international quality standards that define We have taken an entirely different approach to accreditation, and hospitals are really responding, says DNV Healthcare USA Inc. President Patrick Horine. 630-792-5787 | lberkeley@jointcommission.org. 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. Accreditation | We focus on achieving this aspect at every survey. Whether certifying a companys management system or products, accrediting hospitals, providing training, assessing supply chains or digital assets, DNV enables customers and stakeholders to make critical decisions with confidence, continually improve and realize long-term strategic goals sustainably. to review your manual, check procedures, to see your facilities, and briefly check the implementation of your management system. if6&a<=h19;G;:1/SVyB~szQxLgF/94|249#5}Z.+2P#Ncj&qd>ezUL!U&^bezdif++ 0F5/*36Xkm2EI5 y|d04_4_4U. 38cWuc5Sgp:|z] b#THp.'y9Q"dC) XyBlY0,REC-;BfKg%k Gn#A &5B.69e@CqL2{8ZJaC3}vS~ ~l }A}BB-P^I1d}F +R5:>BK5F#A05Vvm{H74` &ixTeG'8T qm|/.mF}K"&Et:rPdj'wj,QmfKh!ynoiwazxC4;oVO ^W[]|rzG k% Search our services and programs offered by our experts at our hundreds of locations throughout Western New York and the Finger Lakes region. Our Privacy Policy | 8618 0 obj <> endobj Following a positive decision you will receive the certificate shortly thereafter. endstream endobj startxref Using an accredited third party certification body/registrars com Jointcomission. endstream endobj 138 0 obj <>stream 0000012451 00000 n 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. AORN statement on nurse-to-patient ratios. Compliance is viewed as a 3-year WebThis background is fascinating in view of The Joint Commissions (TJC) history. Organizations seeking CMS approval may choose to be surveyed either by an accrediting body, such as the Joint Commission, DNV, and HFAP, or by state surveyors on behalf of CMS. You must complete the Participant's Agreement in order to access your purchased NAMSS Education. The International Standards Organization (ISO) Web site. Reflective of an organizations performance with respect to Joint Commission standards and elements of performance (EPs).Transparent all components of the process are fully disclosed to accredited and certified organizations.Easily understood by all involved parties.More items Access our full portfolio of public and private courses, including CHOP Certification. Find out more about our accreditation, certification & training programs. Driven by its purpose, to safeguard life, property, and the environment, DNV helps tackle the challenges and global transformations facing its customers and the world today and is a trusted voice for many of the worlds most successful and forward-thinking companies. trailer An integrated health services organization serving the people of Western New York. 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. ISO is the International Organization for Standardization. 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? 156 0 obj <>stream Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09-02.pdf. 0000003960 00000 n [lW7wI/_./-";)n*R+lx-I$,4|t*0#__ l) Contact South Central Regional Medical Center, Hospital Affiliation Request | DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. DNV Healthcare introduces a hospital accreditation program for stand-alone Psychiatric Hospitals, part of our dedication to helping hospitals improve quality, patient safety and healthcare delivery. A successful management system is one that is improved on a continual basis. NIAHO is the National Integrated Accreditation for Healthcare Organizations and encourages collaboration between different hospital departments. hbbd```b``= "@$nDEH`=d`L""@$?/O@o_@H b4l4k#%4#3` , The report indicates if your organisation is ready to proceed with the certification audit. The documentation review report summarizes any findings from this process. 1350 0 obj <>stream 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. 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 All surveyors have a healthcare background and specialize in one of three areas: clinical care, physical environment, or quality management. The Joint Commission (TJC) is a non-profit organization that accredits and certifies over 22,000 healthcare organizations and programs in the United States. Therefore, accredited certification consists of a 3-step cycle: To tailor the audit, we need to know what is important to your organisation. What happens if an organisation fails to maintain their management system and certification? 131 0 obj Based on a positive outcome, he/she will recommend certification. DNV prides itself in the ability to relate to frontline staff and leadership, thus putting them at ease. Author Frederick P Franko. hb```b``c`201 +s0 The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. Employee Login | Before the audit starts, you provide input on what operational processes are most crucial to your business success. 0000000913 00000 n These audits confirm your companys on-going compliance with specified requirements of the standard while re-evaluating performance in focus areas. 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. 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. Learn how to plan your visit or hospital stay, pay your bill, contact us, and more information about visiting any of our facilities. Admin, South Central Family Medicine & Urgent Care, Directions to South Central Regional Medical Center, Where to Get the Best Care and When to Go. In addition to Department of Health and Joint Commission program compliance, all of our hospitals are accredited by DNV Healthcare. DNV has a transparent procedure for suspension or withdrawal of certificates. 0000006234 00000 n endstream endobj 155 0 obj <>/Size 127/Type/XRef>>stream DNV draws on its wide technical and industry expertise to help companies worldwide build consumer and stakeholder trust. WebThe organizations are surveyed annually. This process ensures a full and timely understanding of the standards. The important role of the Joint Commission AORN J. <]>> 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. Similar review also applies in cases of suspending or restoring certification or withdrawing the certification. We have to get a clear understanding of your business strategy and conditions that affect your ability to reach said strategy. 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) Findings, including non-conformities, and conclusions are presented at the end of the audit in a closing meeting and included in the audit report. HSMo0+TR E9dR-,Q In the few years since DNV Healthcare became the first new 1327 0 obj <> endobj 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 Our surveyors employ a variety of methods for assessment, including staff interviews, medical record review, organizational document review, building and offsite visits, as well as patient interviews and feedback. cuup}c~*_3:!RvpgI(@6a^@IiPo}f$@ L9qdzD AY:RR' 4PQqhxitI3\! In recent years, DNV have been challenging TJC in the USA. DNV is a global independent certification, assurance and risk management provider, operating in more than 100 countries. See upcoming training courses. 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. All rights reserved. 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. 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\) Both your management system and certificate have to be maintained. South Central was the first DNV accredited healthcare organization in Mississippi. "F$H:R!zFQd?r9\A&GrQhE]a4zBgE#H *B=0HIpp0MxJ$D1D, VKYdE"EI2EBGt4MzNr!YK ?%_&#(0J:EAiQ(()WT6U@P+!~mDe!hh/']B/?a0nhF!X8kc&5S6lIa2cKMA!E#dV(kel }}Cq9 0000009113 00000 n n3kGz=[==B0FX'+tG,}/Hh8mW2p[AiAN#8$X?AKHI{!7. The trademarks DNV GL, DNV, the Horizon Graphic and Det Norske Veritas are the properties of companies in the Det Norske Veritas group. 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. Fundao So Francisco Xavier / Hospital Mrcio Cunha. BPHC Accreditation Initiative . 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. As DNV hospitals often say, ISO provides the structure for the staff to focus on This accreditation underscores our commitment to developing and continually improving quality and safety for employees, patients and visitors throughout our system. 847-324-7487 | msweeney@aaahc.org . 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. 0000003466 00000 n 0000001372 00000 n 2010 Mosby, Inc. Det Norske Veritas (DNV) is a global quality Available at: www.iso.org/iso/home. We use cookies to help provide and enhance our service and tailor content. WebThis approval provides hospitals with another accreditation option in addition to the Joint Commission and the American Osteopathic Association. The scope of certification may however need to be expanded or reduced due to factors such as acquisitions, downsizing, adding new divisions etc. WebThe important role of the Joint Commission. endstream endobj 1332 0 obj <>stream The certification audit consists of informal interviews, examinations, observations of the system in operation and review of relevant documentation. DNV Accreditation is based on the companys innovative NIAHO standards. WebAccredited hospitals. WebDNV offers a number of standards - Hospital Accreditation, Stroke Center, Orthopedic Service Line, Infection Risk and more. %PDF-1.4 % Infection Control & Hospital Epidemiology (2020), 41, 13441347. Frustrated with The Joint Commission, Midland Memorial Hospital (TX) made the shift to DNV this year, says accreditation specialist Lisa Williams, PT, MS, HACP.The hospital had already been looking at the Centers for Medicare & Medicaid Services' conditions of participation in 2002 Jun;75(6):1179-82. doi: 10.1016/s0001-2092(06)61621-9. Top management should be involved at this stage. Webknown as DNV Accreditation, they came equipped with the experience of TUVs previous effort to become deemed and their National Integrated Accreditation for Healthcare Accepted manuscript, pp. DNV understands the important role Psychiatric Hospitals play in caring for the underserved and underinsured population. AORN Guidance Statement: Perioperative Staffing. DOI: https://doi.org/10.1016/j.mnl.2009.10.004, The International Organization for Standardization (ISO), To read this article in full you will need to make a payment. Infection Control & Hospital Epidemiology,40(9), 1066-1069. doi:10.1017/ice.2019.164. 120 0 obj DOI:https://doi.org/10.1017/ice.2020.1437. Why? 630-792-5509 | rzordan@jointcommission.org. WebIntro to DNV and NIAHO. 0000020794 00000 n 0000005251 00000 n HlSn0}W*vHUYii& 3kj`{YiDsqHI)P(J|\*|H X(PnFc'G]=/L$)$M[x6i; `9aDv}~2$eY@5 f'N^O_SFda55,EgsHwJWP'* xi.qDU_4%4reA)4zq0l>vf_R3;hxxlqn=hK`I8BL!eAS$O=pJI`2xKtQ_hv6 bG2u.S?)UIraqn/S#5gCi3+D WmBK%# %,,`0,XA!rd{ey` F7 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 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. 0 Learning happens when staff are comfortable and not intimidated by the process. When found compliant, we issue the certificate. Digital monitoring of medium-voltage cable networks, Offshore classification fleet in service, Electric grid performance and reliability, Reliability, availability and maintainability (RAM), Ship management, operations and ship design, procedure for suspension and withdrawal of certificates. endstream endobj 1328 0 obj <>/Metadata 142 0 R/OCProperties<>/OCGs[1339 0 R 1340 0 R 1341 0 R]>>/Outlines 204 0 R/Pages 1318 0 R/StructTreeRoot 287 0 R/Type/Catalog>> endobj 1329 0 obj <>/ExtGState<>/Font<>/Properties<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1330 0 obj <>stream 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 For more information about DNV, visit www.dnvcert.com/healthcare. Lab Specimen Guideline | We felt that by moving from Joint Commission accreditation to DNV accreditation we were taking our organization to an all new level, he said. N')].uJr Unlike previous approaches to accreditation, DNV focuses on what works best for each hospital and therefore opens the door to innovation. The initial visit can be combined with the documentation review. WebThe more variables and inter-dependencies in you organization, the more relevant ISO becomes. ISO is recognized by businesses around the world as the benchmark for continual quality improvement. Agreeing on focus areas is a collaborative effort, and our auditors can help suggest focus areas if necessary. Learn About Accreditation Survey Public Records Policy | 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 Grid last updated: July 2022, National Association Medical Staff Services. x- [ 0}y)7ta>jT7@t`q2&6ZL?_yxg)zLU*uSkSeO4?c. R -25 S>Vd`rn~Y&+`;A4 A9 =-tl`;~p Gp| [`L` "AYA+Cb(R, *T2B- The ability to integrate ISO 9001 quality standards with our clinical and financial processes is a major step forward.. CMS-2895-FN, September, 26, 2008. These surveys, often routine or planned to certify our specialty programs, look at our communication processes, governance, processes, standardization, safety precautions and outcomes. There is always an opportunity to improve. v4?fBHQ [C. Lesho, E., Hix, J., Bronstein, M., Shastry, S., Hanna, J., Scroggins, G., & Grieff, M. (2019). PMID: 12085409 Joint Commission on Accreditation of Healthcare Organizations* / history Contracts with insurers may require certain accreditation and may need renegotiation Will there be a saving in direct and indirect accreditation costs? South Central is a public, not for profit hospital owned by Jones County, MS, who has an economic impact to our local community annually of almost $200 million. This 2.5-day course is a basic course designed to train healthcare professionals in the principles and requirements of DNV's approach to hospital accreditation. 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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