By Michelle Pasqualetti, Regional Pharmacy Director

There are several hospital accreditation programs that healthcare facilities can work with to ensure they are compliant with all codes and best practices. One of these accreditation groups is DNV, which has accredited more than 600 hospitals in the U.S.

DNV aims to create a sustainable culture of quality while simultaneously empowering hospitals to achieve their accreditation, financial, patient safety and quality goals. DNV’s requirements provide healthcare organizations with a clear framework for the improvement of patient safety and quality of care in a language that healthcare workers intuitively understand. These requirements cover the hospital pharmacy, promoting patient safety and quality assurance. 

DNV is the only accreditation organization that integrates ISO 9001 quality management standards with the Medicare Conditions of Participation (CoP). The more variables and interdependencies in your organization, the more relevant ISO becomes. ISO provides the structure for the hospital staff to focus on common goals, such as patient care and safety. ISO 9001 puts everyone on the same page, turning individuals into teams, and teams into high-performance enterprises. 

Background on DNV

DNV on-site surveys are performed every year, which has its benefits. For one, if there is an issue it can be found and fixed within the year instead of festering for up to three years. 

DNV’s accreditation programs directly address CMS requirements and leverage the guidance and best practices of clinical specialty organizations across healthcare, including the:

What DNV Looks for from Hospital Pharmacies

The Medication Management Standards that DNV uses to certify hospital pharmacies are comprehensive in scope. Painting with a broad brush, the standards check against the following:

  • The pharmacy service has written policies and procedures to ensure effective medication management practices that meet the needs of the patients. 
  • The pharmacy is directed by a registered pharmacist responsible for developing, supervising and coordinating all the activities of the pharmacy services, and has an adequate number of qualified personnel to ensure effective medication management services, including emergency services. 
  • Drugs and biologicals are prepared and administered in accordance with federal, state and local requirements, recommendations of professional organizations and accepted evidence-based, professionally recognized standards of practice.
  • All compounding, packaging and dispensing of medication is supervised by a pharmacist. A written training program and SOPs are also required.
  • All drugs and biologicals are controlled, secured and distributed in accordance with applicable evidence-based, professionally recognized standards of practice and consistent with federal and state law at all times. 
  • Outdated, mislabeled or otherwise unusable medications are not available for patient use. 
  • Medications prescribed without a specific duration or number of doses are automatically stopped after a reasonable time predetermined by the medical staff.
  • Blood transfusions and intravenous medications are administered in accordance with state law and approved medical staff policies and procedures. In case of a medical malpractice, a professional medical malpractice attorney should be consulted.
  • Hospitals may use pre-printed and electronic standing orders, order sets and protocols for patient orders.

How We Can Help

A helpful service PharmD on Demand offers is DNV survey prep. We visit our hospital pharmacies ahead of time and perform a mock survey onsite with our pharmacy director. We’ll also perform an interview and review all the medication management standards. 

Oftentimes, our surveys can uncover issues that can be brought up to date before the DNV surveyor comes on site. These extra steps help ensure our facilities and staff are fully prepared for the DNV survey. By being proactive with our centers, we also avoid any non-conformities from a medication management perspective. 

If you have questions about DNV accreditation and how we can help ensure your pharmacy is meeting every standard, please feel free to reach out to me. You can email me at