Mary Ellen Conway, RN, BSN, is president of Capitol Healthcare Group, LLC in Bethesda, Md., which provides health-care management expertise in accreditation preparation and survey follow-up, operations assistance, design of quality improvement programs and outcomes measures. She can be reached at 301-896-0193 or www.capitalhealthcaregroup.com.
As the New Year is beginning, it seems fit to review one of the annual requirements we have from our accreditors: Annual Education. The Centers for Medicare & Medicaid Services (CMS) Final Quality Standards require education be provided to all DME “technical staff,” which includes any staff member who delivers or instructs items in person or troubleshoots equipment over the phone. Compliance with The Final Quality Standards is enforced by your accreditor, and in doing so your particular accreditor’s standard may list a yearly amount of hours (and sometimes the topics) of education that suppliers must provide to their DME staff who instruct patients.
The Annual Education standard is commonly found deficient on re-surveys, especially for small suppliers, as they often “forget” to create their calendar, and even if they do create it suppliers may not implement the schedule as planned. Meeting this standard can be less complex for a large supplier who has an electronic system that tracks and manages employee compliance. Some small- to medium-size providers offer that compliance with this standard is challenging. But requirements such as these do not have to be cumbersome. Compliance can be very routine and reasonable. If this has been a challenge for you, why not adopt some best practices implemented by successful small suppliers?
Start by making sure that you have a standard sign-in sheet that you use to document staff attendance/participation in each educational program that can be filled in a binder labeled “Annual Education.” The sign-in sheet can be a standard form that is completed by hand at each session. It needs to have blank lines where information such as the date, topic and speaker/item used can be completed, as well as enough room/lines for each attending staff member to sign. File the completed sheets for each program in this binder with any materials/handouts provided at the session, or at a minimum a short description of what the program was. Place a copy of the 2013 calendar you create as page one of the binder along with the original sign-in sheet and blank copies in the interior left-pocket in the front so that you house everything in one place. Add 2014, 2015 and subsequent years on top each year so that when your surveyor comes onsite for re-survey you can simply hand them the complete binder rather than struggling to gather information and be able to show immediately that you have met your requirement. As new accreditation cycles begin, start a new binder.
In terms of the schedule start by sitting down now, in January, and creating your plan for the entire year. Start your schedule with February and plan for at least 6 to 8 one-hour programs for the year, being sure to schedule at least the minimum sessions required by your accreditor (if you have a minimum number of hours required). Don’t schedule programs during your busiest months, which may be November/December or might be a spring or summer month when you are short-staffed due to vacations.
For the 2013 calendar year, schedule a day and time during these months for a “Munch and Learn.” Pick a consistent time—early morning, during lunch, late afternoon—or more than one time during a single day, whatever works best with your staff and their availability. You can certainly provide light snacks, food and/or drinks, but you don’t have to. You can tell the staff to brown bag their lunch or snack that day and bring it with them. Select a day mid-month on a Tuesday, Wednesday or Thursday so that you are not scheduling a program on your busy Mondays and Fridays at the beginning and end of the month.
For the first few months you schedule, both at the beginning and end of the year, pick a few topics to implement by video. You may have a video library that you can review, or videos you can purchase, from which you can select routine topics such as OSHA, safety on the road/warehouse, security and more. These should be topics that your staff can review online as they gather around a computer with an Internet connection or in a conference room equipped with a DVD player and a screen. Member groups such as VGM and The MedGroup offer their members (and sometimes non-members) access to excellent, high-quality video educational programs. You might also review what video materials are available from your local library or health department that you can rent or borrow.
For the next few programs you schedule plan to utilize booklets with post-tests that can be purchased from health care publishing companies such as Channing-Bete, Coastal Communications and more. Do an Internet search to find the litany of material available. Pick basic topics such as cultural diversity, infection control, bloodborne pathogens and others from their list of available booklets. Be sure to order an adequate amount of booklets so that each staff member will have one, and order them in January or February so that you will have them for future use later in the year. Plan to distribute the booklet at the beginning of the designated month and have a date by which the completed test, found at the back of the booklet, needs to be returned to be graded and filed in the binder. This is an easy way to provide education and meet your educational requirements without the staff needing to come out of the field, and it should certainly be included in your calendar at least two or three times a year.
Don’t think that you or your staff are the only ones who can provide in-services. Utilize local and regional experts in your community to provide in-person presentations whenever possible. You might be able to invite speakers who can offer a local perspective on such topics as resources to utilize in your Emergency Preparedness Plan, Fire Department staff to review concerns of fire safety, a Discharge Planner from a referring facility to discuss needs and concerns, and similar types of individuals. Start talking to these folks now so that you can get on their 2013 calendar well in advance.
Finally, leave a “hole” in one or two months with a topic TBD (To Be Determined). This helps you keep your schedule with a little bit of flexibility so that if a timely teleconference topic becomes available, or if a manufacturer rep calls on you and wants to offer an in-service, you can bump a previously scheduled video or booklet offering to another month.
As you plan to meet your requirement from your accreditor, include an extra topic or two so that you are covered in case something happens and you have to cancel a speaker. Don’t forget, you can always offer more than the required number of sessions if you end up adding programs along the way. If you take an hour now to sit down and create an annual schedule, you will have a workable plan in place that you should be easy to maintain. If you keep to the schedule you create now, with diverse types of programming, you will be able to meet your minimum requirements and ensure that this standard is met—and maybe even exceeded!