Back in 2005, while attending an educational seminar at Medtrade, one of the presenters strongly advised that any company who was not currently accredited should begin the process as soon as possible.
At the time, it felt like mandatory accreditation was a long time off, and I really did not have the time, the energy, or the money to go through what I thought was going to be an almost impossible process. I began to talk to colleagues who had been through accreditation, and most of them said that while the process was painful, the outcome was beneficial to their companies.
I also began visiting some of the accrediting bodies at their booths that year, and I realized that while the desired outcome was universal, the method in which that was achieved was not the same for each body. Depending on the amount of “hand-holding” you felt you needed, some of the accrediting bodies had a more intimate relationship with you as their customer. In most cases, the more guidance, the higher the costs.
Getting the Process Started
I went back to my business and broached the subject of accreditation to a loud round of groans. Most of us had never been through accreditation, but a couple had, and they were the most dubious. Needless to say, I was not feeling too good about my impending decision to commit, but we decided as a company to pursue JCAHO (Joint Commission on the Accreditation of Healthcare Organizations) accreditation.
At that time, we did not know who would be considered a qualified accrediting body, but we were confident that when the selections came, JCAHO would be one of those who was recognized. Also, the estimated costs were less than I anticipated, and in one case quite a bit lower than one of the other bodies I interviewed.
I cannot write about how others achieved accreditation, and I don’t have experience with any other bodies, so my perspective on this subject is strictly my own as it relates to my experience.
The application process was submitted online, and it took about half a day to complete. The background information gathered was similar to the completion of a Medicare application as the information about business owners, shareholders, other businesses, business locations, contractual obligations and financial information were gathered. The financial information included bank information, revenue information, vendor information, and the number of patients that we had recurring rentals out to at that time.
That information formed the basis of JCAHO’s acceptance of us as a customer. Accessing the JCAHO Web site through a login would become the primary way to maintain communication through the accreditation process.
Once our application was accepted, we chose to hire a consultant to help us develop the policies and procedures that were going to be reviewed as part of our accreditation. It is not mandatory to have a consultant help you, but we found that help to be of real value, and well worth the additional cost.
While the regulations of JCAHO accreditation are very specific and quite extensive, the consultant brought the policies into the real world by applying them specifically to our business. She spent about three days in our business going through a mock inspection, and at the end she gave us a very detailed list of objectives, each tied to a timeline and a priority. This was probably the most helpful to us, as it allowed us to break down what seemed like an impossible task into smaller, more manageable and achievable tasks.
Taking Credit for Compliance
One of the points that the consultant made during this time was that a lot of what we were doing was already compliant; we just weren’t giving ourselves credit for it by documenting it. I suspect that many companies who are intimidated by the thought of accreditation are not giving themselves enough credit for the processes they are already using. If you’re one of these companies, you just need to develop a method of documenting what you do. You may already have some of the tools you need to help with the documentation embedded in your software.
Our consultant came in May 2006, and we had until August 2006 to review and refine our practices. By August we were prepared to operate under the mandatory four months of compliance that JCAHO required prior to our survey.
We used that time between May and August to assign each department and each employee within that department some duty related to the detailed list of objectives. If the delivery vehicles needed to be brought up to compliance by the addition of eye-wash kits and fire extinguishers, then the drivers and their manager were tasked with getting the vehicles ready for inspection. Once the vehicles were compliant, the drivers practiced the routines associated with the policies daily until it became habit.
We trained together on the proper use of fire extinguishers, held a fire drill, mapped the exits from the building, added signs regarding hand-washing, and developed a phone tree for emergencies. The billing department was responsible for charting denials, the technicians were taught how to properly clean equipment and how to separate it from equipment that had not been cleaned, customer service refined the handling of files, administration needed to develop an organization chart and a budget, and everyone practiced and practiced until it became routine.
We understood from our consultant that the surveyors would take a patient file and trace it from the moment the referral came in all the way to the final receipt of payment. All the aspects associated with that file would be reviewed.
And Practice Makes Perfect
Imagine a typical new patient with a rental wheelchair, and everyone who would be involved in that piece of equipment. Each of those people need to have training to show their competence in providing that equipment, from the intake person all the way to the billing and receiving staff. You probably have done the training, and you showed the patient how to use the equipment, but has it been documented?
Documentation of employee training is critical. Every Monday, we held a meeting to review the tasks that each of us was working on, and we specifically measured our readiness in terms of percentage of compliance.
In my opinion, no one person can manage a project like this by himself. Each department needs to know what to expect from the surveyors in terms of the policies, and by having refined and practiced them for months in preparation of the survey, when you feel you are 100 percent, there is no need to fear the survey.
The day the surveyors came, we did not know what to expect, but we were prepared to show them what we had implemented. It quickly became apparent that the surveyors were there to help us achieve accreditation, not to prevent us from being accredited.
They spent two days going through every aspect of the business, from the cleaning area to actually going out to the patients’ homes on a couple of deliveries. They went through the tracking process and reviewed each step, including the history of the equipment and its maintenance and cleaning. They asked questions regarding our policy and procedure as it relates to the regulations, and they made comments and suggestions on ways to improve. They interviewed the employees to gauge their understanding of their job and their compliance.
The underlying element was always patient care. All of the processes we were using always tied back to the patient. When employee competence and training was being evaluated, the key was that a properly trained employee would be able to properly train the patient.
You will not be perfect; there will be some things that still need work. Those will be identified, and a method of correcting and measuring will be applied to the deficiencies so that you can become the best you can be.
Accreditation is serious and it cannot be done overnight; however, the process is not impossible. The steps to achieving it can be reached, and with diligence and teamwork, you will succeed in this accreditation process and your company and your patients will be better for it.
