Harry Truman, the 33rd President of the United States had a famous slogan, which appeared on a plaque on his desk: “The Buck Stops Here”. Referring to “passing the buck”; that is, shifting blame or responsibility, the saying demonstrates a person’s willingness and ability to take responsibility, find solutions, and lead by example.
In the DME industry, we have all manner of organizational structure ranging from publicly traded mega-corporations all the way to other end of the spectrum: one and two-person companies where the owner is also the sole employee performing all tasks and functions within the organization. Some owners are hands-off investors who turn over all aspects of the operation to employees. Others work within their own companies in a variety of roles ranging from clinician to operations manager to CEO.
Accreditation standards look at leadership within an organizational structure and reference this aspect of operations throughout the CMS Quality Standards and thus throughout accrediting organizations’ standards. Leadership’s role within the company, the chain of command, and issues of continuity of care when leaders are not present are important issues that pop up in both the standards and the survey process. Two specific standards specifically outline the expectations for leadership in accreditation.
Leadership and Administrative Structure
The organization provides leadership and designates one or more persons with authority, responsibility, and accountability to direct the organization and its key activities and operations. The organization must list an administrative structure that includes a current organizational chart recording all job titles of positions or classifications in the organization. The chart provides information about administrative management and chain of command.
With ORG 3, the organization is asked to list out and document the chain of command and organizational structure using an “organizational chart” that lists job titles, departments, and a reporting mechanism (chain of command). The organization submits the organizational chart into their HQAA workroom during the pre-survey phase. During survey, the surveyor uses this chart to become acquainted with an organization. (Insider Hint: I print one up and bring it with me to the survey, making notes on it at the opening conference as I meet the staff in person).
Additionally, it is pretty standard to ask employees as they are being interviewed questions about who they report to, who manages them, who makes the schedule up, etc. Employees should be aware of who they report to within an organization. Supervisors and managers should be able to describe how they communicate with their staff, how they validate staff competence, and what role each of their employees play within the organization.
So, ORG 3 sets forth a requirement for an organization to implement and document the administrative and operational structure of a company whether large or small and give authority to the leaders, supervisors, and managers. ORG 4 goes a step beyond that and states that an organization’s leadership is effectively “governing and managing” the organization.
Standard ORG 4
Leadership/governance ensures that the organization is governed and managed in a manner that promotes continuity and responsibility and is accountable for the organization’s operations.
ORG 4 requires organizations to set forth a policy that defines the leadership structure, governing responsibilities, and accountability. Not only who reports to what supervisor, but what expectations does the organization have for the supervisor. Who’s in charge when the owner/boss is out of town or absent? Who has the checkbook and authority to spend money on purchases? Who follows up on complaints from customers?
A typical ORG 4 policy would flesh out the administrative structure and define what “authority” each member of the leadership team has with regards to making decisions and managing the company. Keep in mind that leadership needs to concern itself not just with supervising employees and signing checks for purchases and payroll, but also with “mission and vision” issues as well. The policy should spell out who does strategic planning, who monitors quality and performance improvement and how do the leaders collaborate on QI/PI activities, and who in leadership is responsible for the budget and long-term financial planning.
Surveyors will ask staff about how they are supervised and managed. They will also certainly ask leadership about how they lead. Typically, the surveyor will spend time with the owner (or his or her designee) at the opening conference and also make time to talk to them one on one during the survey. Owner and/or leadership should expect to answer questions about reporting structure, the organizational chart, how decisions about spending money are made, budget, hiring staff, allocating resources, following law and regulation, accountability within the organization, compliance, and quality improvement.
Accreditation standards concern themselves with the structure of procedures relating to leadership (such as reporting accountability and organizational structure) and do not dictate to a company how to accomplish this. However, surveyors can usually tell when organizations are well managed by effective leadership. When leadership is effective, the whole organization runs smoothly. When it isn’t effective, the opposite is true. Organizations don’t run themselves and an effective leader or leadership team is essential to any operation or endeavor regardless of the industry or the size of the organization.
Over the years, I’ve seen my fair share of inspirational posters hanging in owner’s and manager’s offices. Perhaps my favorite was a quote by John Maxwell. Maxwell wrote several books on leadership that are pretty good reads. The Maxwell quote that stuck with me captures the essence of leadership:
“The pessimist complains about the wind. The optimist expects it to change. The leader adjusts the sails.”
It is important to take the time to evaluate and critique your organization’s leadership structure and make sure the leaders are adjusting the sails effectively.