Say Their Names: Identifying Officers & Titled Roles in Your DME

General Colin Powell once famously stated: “Organizational charts and fancy titles count for next to nothing”. Depending on the context or the situation, that may or may not be true. But with all due respect to General Powell, identifying certain titles and positions within your organization and pinning them on an accurate organizational chart is a necessary requirement and the basis of several accreditation standards. The standards require naming the actual persons and titles and reporting mechanism within your organizations.

The basis of these standards and the first standard worth mentioning is ORG 3, LEADERSHIP AND ADMINISTRATIVE STUCTURE. The standard requires the designation of staff members with authority and responsibility to direct operations and activities within the organization. It requires an “organizational chart” listing the positions by job title and delineation of the reporting mechanism, that is, the chain of command. An organizational chart shows all the positions within a company and who they report to as supervisors. This creates accountability and all staff know what their responsibilities are and who directs them. The organizational chart should be written into policy and given to all staff. It is a document that HQAA asks for in the workroom during the application process and one that all staff should be aware of and able to access.

The following standards specify the identification of an officer or staff member to take responsibility for some task or area within the organization:

• ORG 5, COMPLIANCE requires the designation of a “Compliance Officer” tasked with overseeing the compliance program at your organization.
• ICS 1, SAFETY/INFECTION CONTROL OFFICER requires policy relating to the responsibilities of a safety and infection control officer to monitor safety within your organization. Besides the policy, it also requires naming the individual or individuals given that responsibility. This can be the owner, especially at a smaller organization. It can be the same person for both tasks (safety and infection control) or it can be two different people or departments.
• QM 1/QM 3, QUALITY IMPROVEMENT describes the requirements for your organization’s performance improvement or quality improvement program. The program monitors operations and studies “indicators” which measure your company in various areas. The study of the outcome of these indicators can help dramatically improve operations. The standards require the designation of a committee and a chair person for the QI (or PI) committee. Again, depending on your organization’s size and scope, this might be a one-person committee or it might be many people from different departments and branches.
• CRS 3, QUALIFIED STAFF AND SUPERVISORS. This standard, a requirement of any company providing clinical respiratory services (CRS), dictates that you have “qualified” (competent and appropriately licensed) staff and supervisors. The clinical staff must be supervised by someone with similar credentials for the same reasons that competency assessment is done by similarly credentialed and/or qualified staff.

Another important standard when talking about naming names and titles is PRO 5, DISCLOSURE. Disclosure refers to letting appropriate agencies, entities, and payer sources have access to documents from your organization such as licenses, policies, patient charts and billing records. An important component of that disclosure is that payer sources such as Medicare must have access to information regarding who owns a company. This disclosure allows government agencies to monitor compliance with a wide range of regulations such as Stark Laws and the OIG’s Exclusions Database.

To review, your policy and procedure manual should name the following staff members:

• Compliance Officer
• Safety Officer
• Infection Control Officer
• Quality Improvement Committee & Chair
• Clinical Supervisor (if providing CRS)

All positions and job titles should be provided on the organizational chart and the information should be available for entities such as Medicare and your accrediting body per the PRO 5, Disclosure standard. The organizational chart should be incorporated into your company’s daily operation and should accurately reflect the actual structure of various departments and how they report up to supervisors, management, and ultimately the owner(s). Staff should be aware of the organizational chart, at least as it relates to them and their job duties and supervisor. Most organizations include it in the initial training and orientation for new employees. When it changes, the changes should be communicated to all staff as well.

With a nod to General Powell, I’d submit that “organizational charts and fancy titles” actually do count for something—at least in the DME world. They are required and necessary. More importantly, they are useful and help an organization with consistency and structure in daily operations.