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Marcie Hopkins, U of U Health
What is DNV? And Other Burning Accreditation Questions
Chief Quality Officer Sandi Gulbransen and Accreditation Manager Kemper Funk provide insight on our partnership with DNV, how accreditation contributes to the safety of our patients and staff, and what to expect during our upcoming evaluation.

ealth care organizations utilize accreditation programs to provide a framework for meeting standards of care and to improve patient safety and quality outcomes.

What is DNV?

Our accrediting body is DNV, a global organization that has established world class hospital accreditation standards using their exclusive Risk Based Certification methodology. DNV surveyors visit U of U Health annually to help identify where to focus our improvement efforts while also assessing risk. Achieving and continuing hospital certification requires three steps: initial certification, annual maintenance, and re-certification every three years.

How does this impact our organization?

DNV is a partner in helping us remain financially stable, patient-prepared and staff safe.

The US Government’s Centers for Medicare and Medicaid (CMS) requires accreditation in order to be reimbursed. This is achieved through a survey conducted by the state on behalf of CMS, or through a national accrediting organization, like DNV, that has been “deemed” or recognized by CMS for meeting and/or exceeding Medicare’s requirements and demonstrates a similar survey process.

Although receiving Medicare and Medicaid funding is essential for our organization and our patients, it isn’t the only reason we do it. Being accredited is best for our patients – it means we are holding their safety and the safety of our staff to the highest possible standard. It is important that we always operate in this mindset – not just when our survey is right around the corner.

Why do we partner with DNV?

We have partnered with DNV because their processes closely align with our vision and values. Together, we strive to make our organization safer and more reliable. Just like there are alternate routes from point to point in our navigation systems, not every organization meets standards in the same way. DNV allows us to evaluate the standards and design our own path to achievement.

Transparency is key in our relationship. Sometimes, we haven’t quite hit the mark yet, but if we communicate where we are in the process and outline progressive work, DNV is supportive and offers guidance. 

What can you expect during a DNV visit?

Our annual evaluations take place each January. DNV is unique in the fact that they always include a surveyor who visited us the prior year to ensure their team has first-hand insight into our progress.

Real-time updates on Pulse. When surveyors arrive, SmartWeb pages are sent out to alert teams. A banner on Pulse directs teams to the Accreditation tile, which provides an agenda and live feed of surveyor progress. This live feed provides real-time detail on what’s happening and where surveyors will be going next. All University of Utah Health team members can post comments on the live feeds. Don’t be shy! This is a great time to give kudos to peers during the survey.

Attention to detail. Surveyors are accompanied by scribes that document important details from interviews with randomly selected staff, or if more information is needed from any areas. Their focus can range anywhere from building structure to pain management, but it is essential to remember to document patient encounters thoroughly because they will likely review patients’ electronic health records.

A helping hand. Surveyors are people just like us – here to help us operate optimally for our patients and our teams.  We shouldn’t feel threatened or overwhelmed during the survey – rather, it is important to be honest, transparent and showcase the exceptional work our teams are doing! It’s not about being perfect – it’s about continuous improvement and being prepared for our patients every single day.


Sandi Gulbransen

Chief Quality Officer, University of Utah Health

Kemper Funk

Manager, Accreditation, University of Utah Health

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