Our Vision for Quality Improvement:

Achieving Sustainable, Exemplary Care through Continuous Quality Improvement.

Our main focus at War Memorial Hospital is providing exemplary care through continuous quality improvement. One of the ways we do this is through our focus on becoming a high-reliability organization, or HRO. The high reliability program is a commitment to ensure excellent quality care is consistently delivered for every patient, every time with a commitment to zero preventable harm.

 


War Memorial Hospital was selected as ONE of NINE hospitals in the State of Michigan to partner with the Michigan Health & Hospital Association (MHA) on becoming an HRO.

By definition, these HROs operate under challenging conditions yet experience fewer problems than would be anticipated as they have developed ways of managing the unexpected better than most organizations.

High-reliability organizations cultivate resilience by relentlessly prioritizing patient safety over other performance pressures.

War Memorial Hospital is committed to creating an environment in which potential errors are anticipated, detected early, and virtually always responded to early enough to prevent errors.

As part of our commitment to quality and patient safety, War Memorial Hospital is becoming more transparent with our patients, community members, and employees.

Part of that effort is having up-to-date internal safety data displayed in public locations throughout our organization, and on our website.

We are consciously tracking and identifying any errors, in order to correct our processes and systems to prevent future errors from occurring.

WMH is committed to transparency. We look forward to providing safe, high quality care to our patients in all-ways

To read our latest Patient Safety Data Report, click here: Patient Safety Data for October 2021

As part of our commitment to zero preventable harm, War Memorial Hospital performs Root Cause Analysis (RCA) on all serious safety events, implementing corrective actions, creating, or revising policies and procedures, and providing staff education.
 
We will also continue to monitor our handwashing rates, and provide education to employees and patients on the importance of handwashing.

Accreditation

War Memorial Hospital is accredited through Det Norske Veritas Healthcare (DNV).
DNV began operating in the U.S. in 1898. In 2008, the Centers of Medicare & Medicaid Services (CMS) approved DNV to assess hospitals for quality of care and patient safety. This means DNV has the authority to approve or disapprove hospitals for CMS reimbursement if they do not meet the standards for quality of care and patient safety.

War Memorial Hospital is accredited through Det Norske Veritas Healthcare (DNV).
DNV began operating in the U.S. in 1898. In 2008, the Centers of Medicare & Medicaid Services (CMS) approved DNV to assess hospitals for quality of care and patient safety. This means DNV has the authority to approve or disapprove hospitals for CMS reimbursement if they do not meet the standards for quality of care and patient safety.

War Memorial must maintain compliance with the DNV NIAHO Standards. The NIAHO Standards are based upon the CMS Conditions of Participation, and therefore assist War Memorial in maintaining compliance with CMS as well. There are 134 Standards that cover a variety of departments and processes within the hospital.

DNV grants accreditation every three years. However, War Memorial undergoes a DNV survey every year to ensure we are maintaining compliance with the NIAHO Standards. This holds us accountable and reinforces our top priority: patient care and safety.

In addition to upholding the NIAHO Standards, War Memorial is also ISO 9001 Certified through DNV. ISO 9001 is a quality management system with specific principles related to: a strong customer focus, using the process approach, and striving for continual improvement. ISO 9001 ensures that quality is consistently improved so errors are reduced. War Memorial has chosen to implement and follow an ISO 9001 quality management system because it will ensure that patients receive consistent, good-quality products and services.

Specific WMH departments also obtain additional accreditation. They are:

Lab — Accredited by CLIA (Clinical Laboratory Improvement Amendments)
Echo Department — Accredited by ICAEL (Intersocietal Commission for the Accreditation of Echocardiography Laboratories)
Cardiac & Pulmonary Rehab — Accredited by AACVPR (American Association of Cardiovascular and Pulmonary Rehabilitation)
Sleep Center — Accredited by the American Academy of Sleep Medicine (AASM)
Pharmacy — Accredited by the Pharmacy Compounding Accreditation Board (PCABC) for sterile and non-sterile compounding