Many in the home medical equipment industry equate policy manuals to their accreditation inspections. And of course, these bulky tomes are certainly a large part of the accreditation and survey experience for every DME. Policy manuals serve as the road map for how work gets done within an organization, a set of rules for the organization, and the document that defines the structure, function, and philosophy of the organization. Let’s look at what a policy manual should contain and how it impacts not only accreditation, but also the overall day-to-day operation of an organization.
A well-crafted policy manual should contain not only policies, but also procedures. Think of a “policy” as a guiding principle, used to steer an organization in some direction. A policy should also define or describe a course of action that is to be taken. “Procedure” is the steps to be followed to accomplish whatever the policy described. The steps are spelled out so that the organization’s staff can accomplish a task in a consistent manner. The policy is the what and the procedure is the how to.
Policies and procedures may be contained within the same document or within two separate documents. They can be hard copy, old-school paper in a binder or electronic files stored on your organization’s hard drive. The key to the success of your policy manual is that it is accessible by all staff and well understood and followed. Since the manual is considered a set of rules, the staff must be aware of the rules and where the rule book is stored, so they can use the manual on an on-going basis to refer back to when questions arise.
DME policy manuals are sometimes written by the staff and management of an organization. Other times, home medical equipment organizations will purchase a template, which uses boilerplate policies and procedures. Both can be used effectively. If you write your own, include the staff that actually has to live with the policy and utilize the procedure as you craft the document. If you use a template, be sure to customize and personalize the policies and procedures so that it accurately defines the principle and the steps to be followed in the procedures. Change the template’s verbiage to match your actual practices, not the other way around.
Written policies and procedures that are required by law and regulation, payer requirements, or accreditation standards include:
- Policy on organizational structure and accountability, usually presented as an “organizational chart” with chains of command and reporting lines
- A “scope of service” statement or description that lists out the services the DME provides
- Policy on conflict of interest and how it is defined within an organization
- Policy on handling ethical issues and/or structure of an ethics committee
- Policy on medical records, which addresses issues such as format (electronic or paper charts), layout of the records, staff access, and how the record is protected
- Policy on record retention
- A disclosure policy that describes how and when information is shared with outside entities
- Human resource (personnel) policies and procedures
- Infection control policies and procedures
- Written disaster and emergency preparedness plan
- Complaint policy describing how complaints are addressed, responded to, and documented
- Procedures for equipment set up/instruction, cleaning and maintenance, and tracking
- Delivery procedures (if applicable)
- Clinical procedures (if applicable)
- Written compliance plan/program
- Written quality improvement plan/program
Keep in mind that law and regulation vary state to state, payer requirements are different depending on the payer source, and accreditation standards vary with the accreditation organizations (AO’s).
Expect to utilize the policy & procedure manual as you apply for accreditation. Most AO’s will want you to submit (or at least reference) some of your policies and procedures as part of the application process. During the survey process, staff should be aware of how to access the manual and expect to answer questions about it when they talk to the surveyor. No need to memorize it line by line or know that the complaint policy is on page 478; just be able to articulate how you access the information and demonstrate that you know how to find the answer if necessary.
Finally, remember that the DME policy manual is a living, breathing document. Surveyors have reason to be concerned when presented with a shiny new manual still in the shrink-wrap. When presented with a well-worn manual with post-it note bookmarks, revisions, and dog eared corners on some of the pages, the surveyor has the impression that the organization actually uses the manual for its intended purpose.
A good, well written policy manual serves as an operational road map for an organization. Maps help keep us on track and prevent us from getting lost. Use your policy manual to keep your organization on track—not just for survey, but every day.