Welcome back to Progress Notes - PRN. In case you missed our last article, PRN stands for Performance, Risk, and NIAHO.

In this issue of Progress Notes - PRN, Ted writes about steps 1 and 2 of the 4 steps of Value Added Auditing. It is just a summary for Progress Notes - PRN so he has a link to the comprehensive article which details the steps.

Eric included an article talking about several reasons you and your leadership may be frustrated with your QMS. Did you hire a food critic to teach you how to become a chef?

Also we included an article which was written by our affiliate partner Jeff Harris R.Ph for CERM Risk Insights ( a RISK newsletter BlueSynergy contributes to under Healthcare@Risk)

Implementing Value Added Auditing through a measured approach

In our last Progress Notes - PRN we introduced you to the solution for your internal audit woes. Value-Added Auditing (VAA) is a true organizational performance audit. It is a deep dive into your processes to determine:

  • that financial and operational controls are reliable
  • risk is identified and managed
  • compliance is in place for external requirements (OSHA, NFPA)
  • conformance to standards such as ISO 9001, NIAHO
  • an efficient use of resources
  • and organizational objectives are effectively achieved.

This concept of VAA is based on the book “Value-Added Auditing: The Standard Manual of Risk-Based Process Auditing” by Greg Hutchins, PE, CERM. In his book, Greg identifies four (4) steps in the lifecycle of a VAA:

  1. Managing the VAA
  2. Planning the VAA
  3. Conducting the VAA
  4. Reporting VAA results.

In the attached article, I discuss the first two steps in more detail. Consistent with the measured approach, I would encourage you to introduce the activities in each step in “levels” for implementation, so as not to overwhelm the auditor and the process. I am suggesting that you complete the first level of implementation, master the first level, and so on until you move to the fourth and final level. Over a period of time (2-4 years), you will have implemented a VAA program.

By using a measured approach,

  1. you can help ensure that the audit program is sustainable
  2. and ensure it is producing tangible results.

By design, this is also a progressive process. I know that you are not satisfied with your internal audit results. Internal audit is either not working or not working as well as we have been told to expect. DNV-GL changed the internal audit chapter for a reason. Any better?

History shows that you cannot create a sustainable change in a short amount of time. Implement, sustain and repeat, knowing that each level you master (even the first level) is likely more advanced than your current internal audits’ process. After your implementation is completed, you will have achieved a level in VAA that is producing results that leadership envisioned with the accreditation change to DNV-GL.

The attached article will address levels 1 & 2 of each of the four steps of VAA. In a future article I will discuss and detail the last two levels of implementation.

I would like to hear and respond to your questions, please email me at tschmidt@bluesynergyassociates.com or call me toll free at 1-844-424-7825. Thanks for reading.

(Link to full article here)

3 reasons why your QMS and accreditation is likely frustrating you and disappointing your leadership.

In this article Eric highlights 3 possible reasons why your QMS is acting like a teenager and not maturing as everyone had hoped.

Many hospitals have started the ISO 9001 journey. This journey probably started because the hospital wanted a fresh and new approach with their accreditation. For the first time a hospital could begin to decide how they would meet requirements and not have to abide by a prescriptive way of doing things.

Now the problems begin, so let’s look at these 3 reasons to gain a better understanding.

Continue reading

The single biggest problem in communication is the illusion that it has taken place.” George Bernard Shaw

The following article was written by Jeff Harris R.Ph. Jeff is a respected advocate for patient safety. He is a graduate of Auburn University School of Pharmacy and continues to learn and master healthcare risk, specifically those aspects related to medication management

On January 13th, 1982, an Air Florida passenger jet crashed into the 14th Street Bridge after takeoff from Washington National Airport, killing 74 passengers on the plane and 4 people in their vehicles on the bridge. After reviewing the flight data recorder, it was discovered that the first officer had repeatedly told the captain that something wasn’t right at takeoff and was rebuffed. Instead of assertively repeating his concerns, the first officer finally agreed with the captain that everything was normal.

Continue reading

How do you move your hospital activities to a sustainable improvement platform?

Optimizing your accreditation PRN

Atlanta, GA. January 11 - 15

An accredited training course to train you on:

  1. the ISO 9001:2015 standard
  2. NIAHO
  3. Cost of quality
  4. Performance improvement

Performance based auditing, Risk based thinking, and NIAHO optimization create a solid platform for your accreditation to show sustainable performance. As resources get tighter, this is quickly becoming a common perspective... accreditation should not be overhead. Figuring out how to make this rational move is the challenge. By maximizing your current accreditation requirements you can do just that!

To keep the momentum going after your class, you will receive (2) hours of FREE advising when you get back to your hospital so you don't experience the post training "blues". This is a limited time offer.

Question: What additional benefits could your hospital bring to it's stakeholders if you had more resources?

FREE personal advising webinar promotion

We have 3 different webinar topics to help you transition to the new standard. Each are (1) hour in length and are limited to (5) attendees per session. Limited time offer for the FREE advising with these webinars.

  1. 2015 Transition planning
  2. Changes to the standard
  3. Risk - based thinking

FREE webinar on ISO 9001:2015

We are continuing to offer our complimentary webinar throughout December. There are 3 more opportunities this year.

December 15 at 11am EST & 2pm EST

December 21 at 11am & (2pm is filled)

Have a group of people who can listen in a meeting room, just let us know, we have been able to schedule this webinar to accommodate group training.

Follow us on Social Media.

We engage in current conversation on topics that affect your hospital, patient safety, and risk-based thinking, all relevant and on point.

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In our next issue of Progress Notes,PRN look for

VAA implementation part 2

Defining Risk-based thinking in healthcare

BlueSynergy Associates LLC

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West Chester, Ohio 45069