Quality Improvement

Quality Improvement  

“Every body doing his best is not the answer. It is first necessary that people know what to do.”


"Out of the Crisis," W. Edwards Deming

Crotched Mountain Specialty Hospital is accredited through DNV Healthcare, Inc., meeting all the conditions of participation required for hospitals by the Centers for Medicare and Medicaid Services. DNV Healthcare's accreditation program focuses on achieving the highest standards of patient care through quality management and continuous improvement systems that address patient safety and quality of services. To promote and ensure a culture of continuous improvement, hospital staff at all levels of the organization actively participate in year-long quality committees that address patient care and operations activities.

This culture of continuous improvement includes adopting a quality policy that is far reaching and aspirational, yet able to be actively incorporated into daily activities. It involves all employees in all facets of the organization, including our hospital, school, residential, and community-based services. To that end, we set measurable objectives to guide our work. And we use systematic tools of performance review to help ensure that our patients and clients are receiving the highest levels of quality care every day. We understand that quality cannot be taken for granted – it is never achieved. Rather, it is something that we must always strive to improve. And as we continue to improve, we will better ensure that Crotched Mountain will remain a beacon of hope for the patients, clients and families that depend on us.


Our Quality Policy

Adopted by Board of Directors on Dec. 3, 2010

Through the dedicated efforts of our professional and direct support staff and in partnership with clients, families and communities, Crotched Mountain will be the region’s most effective, accomplished and safe provider of health, therapy, education, assistive technology and residential support services to people with disabilities and other needs. To achieve this goal we are committed to quality improvement through an organization-wide culture that includes all programs, departments, disciplines and services, with the active involvement of all staff, and with the oversight of our governing Board of Directors. As an indicator of our commitment to quality improvement and client safety, we have achieved and will maintain accreditation for the hospital, school and rehabilitation center by meeting and exceeding the standards established by DNV Healthcare, Inc. and other accrediting bodies. Within three years after achieving hospital accreditation we will achieve ISO9001 compliance and certification for the hospital, school and other programs and services of Crotched Mountain.


DNV Accreditation

Crotched Mountain Specialty Hospital is accredited by DNV Healthcare, Inc., a private organization authorized by the Center for Medicare and Medicaid Services to certify that participating hospitals meet the CMS Conditions of Participation. DNV Healthcare integrates ISO 9001 quality compliance systems in its survey. All participating hospitals are required to achieve ISO 9001 level compliance within three years of initial accreditation. The DNV program is not only a new option for accreditation; it is an entirely new approach to accreditation. DNV focuses not simply on auditing the hospital’s business processes but on finding better ways to do things in every department.


ISO 9001

ISO 9001 is recognized by businesses around the world as the benchmark for continual quality improvement. ISO focuses on efficiency of both clinical and non-clinical processes, meaning if we improve efficiency in nonclinical areas as well as patient, student and client care areas, our delivery systems will provide services better and at less cost. ISO 9001 is recognized by businesses around the world as the benchmark for continual quality improvement. Innovative organizations, including hospitals and schools, have started embracing ISO as a way to identify and focus on the most successful approaches to service, care, billing and other critical aspects of running a modern non-profit business.


Quality Committees

Crotched Mountain organizes its quality improvement and assurance program through committees with functional responsibilities for specific areas of focus. The charters of these committees are drawn from the NIAHO® standards of DNV for the hospital and from other accrediting bodies for other programs of Crotched Mountain. These committees report to a Quality Council which itself reports to a Quality Improvement Committee of the Board of Directors. This system ensures that all levels of the organization – from every employee to the governing body – are involved in the quality improvement. The committees are:


  • Client and Patient Safety
  • Physical Environment of Care
  • Infection Control
  • Document Control
  • Utilization Review and Discharge Planning
  • Nursing Leadership
  • Physician Leadership
  • Emergency Preparedness and Response
  • Client Rights and Ethics
  • Corporate Compliance


For more information about our quality initiatives contact:
Michael Redmond, senior vice president and COO
603.547.3311, ext. 1479

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One Verney Drive Greenfield, NH 03047 Tel. 603.547.3311