The Monster Under the Bed?

You’ve waited to become accredited because you thought it was too expensive, too cumbersome and had no relevance to your daily operations. But now, mandatory accreditation is right around the corner — less than one year away for the lucky providers in those 10 areas where competitive bidding will begin.

With CMS slow in giving direction (provider quality standards are currently expected to be released this spring), how can you get the ball rolling? Here’s a way to tackle the project by creating a realistic work plan and dividing the process into manageable components for you and your staff.

Selecting An Accreditor

This is the decision that home medical equipment companies seem to struggle with the most, but once you’ve made your choice, you will be ready to move forward.

As you review their Web sites, talk to their representatives at conferences and call their offices to ask questions, there are several things you should consider when determining which accrediting organization you are going to select.

First, check with the networks and other payers with whom your company participates to see whether they require accreditation by a particular provider. In the next few years, once CMS recognizes and approves HME accreditation organizations, it is logical to expect that most payers, networks and states will recognize those same accreditors.

In the meantime, there are several accrediting organizations working within the HME sector. Check out all of them to see which you think will be the best fit for your business.

Don’t let the cost of the application and accreditation fees be your sole determining factor. You may hear that one accreditation costs $3,500 and one costs $7,000. Ask to whom and how that cost applies.

Is that the cost for a company with fewer than 50 patients on service? Are surveyor expenses and survey day per diems added to this rate? Do you have to hire additional staff to implement and maintain this accreditor’s standards? Do you have to perform a formal update/review? How often? Are their surveys announced or unannounced?

In the end, it may appear that HME accreditation fees are similar — but remember that these accreditors’ requirements are not at all the same. Remember too, this will probably be a three-year accreditation cost. Divide the expense incurred over three years, and take a look at what your requirements are for work during those three years.

Of course this is an important choice, but don’t feel like you are stuck forever. If you decide you are unhappy with the organization you have chosen, you can always decide not to renew your accreditation with that provider. Most of the organizations are very similar down deep — and the most important thing is that you get going now.

Once you’ve selected your accreditation provider, send for their standards and read through them to see exactly what you need to accomplish.

No matter how small your company is, make every effort to involve your staff in the accreditation process. Spread the work among employees, create a work plan that divides the project up into three main areas — administrative, human resources and performance improvement — and set goal dates for the work to be completed.

Consider whether hiring outside help to organize and coordinate everyone’s efforts would be prudent and whether outside administrative assistance is worth the expense. Perhaps a former staff member who is now a stay-at-home mom might be willing to coordinate some of the work for you. Often, just a small amount of assistance can go a long way.

Administrative Tasks

The tasks assigned to the administrative area are those that address the overall business structure and processes of your organization, namely, policies and procedures and standardization of manuals. Your business may be very small or very large, but either way, you must make sure you have documented policies and procedures for all that you do.

• Policies and Procedures Even non-health care franchises like donut shops and tire dealers have policies and procedures that must be followed. This is not some kind of penalty enforced on you. This is a measure of sound health care business that offers support for decisions and expectations based on well-formulated, realistic polices and procedures. As you review your accreditor’s standards, you’ll see what the requirements are for the policies and procedures you will submit for review or to be reviewed during your accreditation survey. To start, look over the table of contents in your company’s policy and procedures manual (whether you’ve created your own or bought one that is prepared) to see that it is up to the task. Make sure that it accurately states your processes, and that you are actually doing what your policies say you are. If you need to, update your policies and remove those for products and services you no longer provide. Revise your organizational chart, gather meeting minutes, ensure that the most recent versions of your handouts are inserted where they need to be and that all revisions or changes to your manual have been made. For example, there may be processes you need to add. Some HME accreditors require a physician licensure verification program; if you don’t have one, you will need to create a program in your office that meets these requirements. Make sure your staff members are aware of how to access your policies and procedures and that they have been updated on any changes or revisions. There may be other processes you need to create, so reviewing your accreditor’s standards with your existing policies and procedures manual is your first task.
• Standardization of Materials With the advent of new products, technologies and therapies, the handouts and materials you provide to patients can become outdated. Sometimes providers could be using one set of handouts in one office and others in another, and they never stop to check. You could be using an old version of a form that is being copied accidentally, or one that doesn’t contain correct addresses.

Make sure that all of the forms you use, all of the handouts you give patients and all of your marketing materials are up-to-date, clean, clear copies that have the correct information. A large part of quality business practice is providing consistent and uniform materials to patients, and it’s surprising how many providers need to stop and get this task accomplished.

Patient educational materials must be current and be provided in clear, readable copies. Make sure you don’t distribute marketing materials for services or equipment you no longer provide, list offices you no longer operate or give out old location addresses.

Human Resources

This component of the work plan includes dealing with personnel files, your competency program, educational requirements and documentation.

• Personnel Files Your company must have a separate and secure personnel file for each employee, including independent contractors. Each file should contain all of the information that your accreditation standards dictate. These items may include any or all of the following: completed application and resume, interview documentation, completed reference checks, copies of professional licenses and validation checks, results of competency checks, educational test results, orientation checklists, job description(s), performance evaluation(s), copy of a valid CPR card, letters of commendation or complaint, etc. Any items with medical information or a date of birth, such as a driver’s license or an I-9 form, are generally required to be held in a separate file. Medical information would include copies of drug testing, physical exams, workman’s comp information, tuberculosis testing dates/results or hepatitis vaccination/declination, etc. These files should be organized in the same way for each staff member and kept in a locked, secure area with access limited only to designated staff members. They should be audited on a routine basis to ensure that all required documentation is present and current. Your company also must have a process to verify the licenses for all licensed staff, such as respiratory therapists.
• Competency Program Most HME companies beginning the accreditation process also need to begin a competency program. “Competence” or “competency” is defined by Webster’s dictionary as “answering all requirements, being suitable.” One of the industry’s current accrediting bodies defines the term as “determination of an individual’s skills, knowledge and capability to meet defined expectations.” A provider, then, must create and utilize a competency program to make sure that everyone representing the company or providing service to patients is competent to do so. This does not mean that the employee simply has a license or passes a written review of information. Accreditors require a program that evaluates an individual’s competency upon hire and generally once every year or two. This can be accomplished through direct observation by a person who is qualified to review and evaluate those tasks. While an owner or supervisor can evaluate the competency of an administrative employee, only a clinically licensed individual can evaluate another clinically licensed person. For example, a respiratory therapist can only be evaluated by another respiratory therapist. If your company has only one RT, you would need to contract with an outside RT to perform the competency evaluation at whatever frequency your policy dictates. All competency evaluations are performed using standardized tools that you can develop or purchase. Companies can use a competency tool for a piece of equipment — a new ventilator, concentrator or electric bed, etc. — as well as a tool to evaluate the employee’s performance, including items such as interaction with patients/referral sources, documentation, etc.
• Educational Requirements and Documentation Any quality assurance program must include education for the staff. Providers can always tell the staff to stay current with topics or show them how to use new equipment, but quality organizations offer employees valuable information on a formal, ongoing basis. Generally, HME accreditors require a yearly educational calendar with a required number of hours for certain topics. This list may change from year to year based on staff needs but, usually, some standard programs are expected to be offered. These include topics such as safety, TB, infection control and handling hazardous materials. Accreditation providers expect you to assess the particular educational needs of your staff and to create a calendar each year that addresses those needs. This education does not have to offer continuing education units and can utilize a variety of formats. Try to complete your calendar by offering various types of programs. You can purchase any of the excellent educational DVDs and tapes that are available on HME topics (and use them on a rotating basis through the years as long as they remain applicable); send staff to local and regional conferences; or participate in teleconferences on topics of interest. Most important, you need to document your staff’s participation in any programs they attend. This documentation can be in the form of sign-in sheets kept in a binder (not necessarily in the employee’s personnel file), and must be readily available. You should be able to demonstrate that each staff member has completed all of your required educational programs for the year. Note, however, that annual CPR certification, CEUs obtained to maintain a state license (as the sole education), or education on accreditation is not always recognized by an accreditation organization as meeting this requirement.
• Performance, or Quality, Improvement Generally, for HME providers, a written plan for performance or quality improvement (PI/QI) is uncharted territory. We are all accustomed to being asked to complete surveys when we get our car serviced, attend a conference or visit a vacation destination. These surveys are really just a component of a PI program.

The basic hallmark of any accreditation program is quality. This includes quality processes, making sure that quality standards are upheld and continuous review to ensure that any areas of concern or deficiency are identified. It also requires self-reporting of serious or dangerous incidents and that they are rectified when possible.

Generally in HME, accreditors require that a provider select several items to track and measure known as “performance measures” or “quality indicators.” These items can be any measure of value such as customer satisfaction, percentage of equipment failures, number of complaints received, time taken to respond to after-hours calls, the number of charts that are complete during an audit or others.

A company selects the measures it plans to track, identifies the team members who will be responsible for implementing the steps of this plan, sets the schedule for examining the results, puts the measurement tools together and implements the process. Home care companies typically measure the results by quarter and create summaries of what they’ve measured.

Often, accreditation organizations require that your results be benchmarked with those of similar companies to determine whether there is a need for improvement or if the results are consistent with others.

PI or QI programs can be created by your own company or also can be purchased. The Centers for Medicare and Medicaid Services will require a PI program, and the agency has preliminarily announced that it that will require beneficiary satisfaction surveys. In starting or reviewing your current PI program, it would be wise to get this indicator included in one of the measures being tracked since it could be mandatory in the near future.

Generally, HME accreditors require that you have at least one quarter of data collected in your PI program in order to submit your application for accreditation.

This is one component of your work plan that you can begin immediately. Once you identify your measurements and get your collection method in place, over the next three months you can gather the data, summarize, benchmark and be in better shape to submit your application.

It’s Not So Scary

Accreditation is really not the scary monster under the bed. It definitely is a challenge, but by creating a realistic work plan with goal dates, dividing the major tasks into manageable components and utilizing your staff or outside help, you can get the process accomplished.

With more than 25 years’ experience in management throughout the health care continuum, Mary Ellen Conway is the president of Capital Healthcare Group, LLC, Bethesda, Md., where she specializes in operations and regulatory issues in home health, hospice, medical equipment and accreditation. She can be contacted by phone at 301/896-0193 or through www.capitalhealthcaregroup.com.

Accreditation Work Plan