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:
Topics: Business Practices, HME Accreditation Requirements, Quality Standards, Compliance, HQAA Accreditation, Patient File Requirements, Employee Training, Renewing Accreditation, Patient Privacy, Materials Management, Personnel Files, Avoiding Deficiencies, Quality Improvement, Complaint Process, CMS, Billing, Clinical Practice Guidelines, Emergencies, Disaster Preparedness, Customer Service, Marketing, Safety Officer, Competence, Warehouse, Oxygen, Delivery, Clinical Respiratory Services, Showroom, Retail, Quality Care, Security, HIPAA
Topics: Avoiding Deficiencies, Compliance, Billing, Employee Training, HIPAA, Delivery, Retail, Warehouse, Showroom, Personnel Files, Materials Management, Patient File Requirements, Process Improvement, Quality, Safety Officer, Quality Improvement, Patient Privacy, Quality Standards
Companies going through an accreditation process usually experience at least some degree of anxiety. The importance of achieving and maintaining accreditation is often “life and death” to an organization—lose it and you may not be able to continue billing or receive referrals from a payer or a referral source. If it’s the first time you’re going through the process, you can also add the fear of the unknown to that equation. Add these factors together and you have a combination that can cause a lot of stress!
The nature of accreditation is that a company embraces a continuous quality improvement methodology and operates its business in compliance with laws, regulations, and industry best practices to the best of its ability. Accreditation is a journey not just a destination – a journey full of learning opportunities, education, and revision and tweaking of your company’s processes and procedures.
That process doesn’t lend itself well to quick “punch lists” and it is not advisable to look for shortcuts along the journey. However,
Organizations are sometimes surprised to find out that surveyors look at various state and federal laws along with accreditation standards during the survey. The fact of the matter is that law and regulation overlaps accreditation standards in many ways and in many places. In fact, many accreditation standards have their basis in law and regulation. Standard ORG 2 states that an organization willdemonstrate compliance with “all required federal, state, and local licenses, permits, certifications, and registration requirements”. It also references compliance with Medicare enrollment standards, meaning that you must comply with the Quality Standards, which were the basis for all accreditation standards. Essentially, what ORG 2 says is that you must follow all applicable law and regulation.
“Ride alongs” are home visits that are performed with a new orientee or current staff member where an evaluator rides along to teach and observe the staff member performing the visit. These visits are typically done during orientation/training and on an on-going basis for competency assessment. These visits ensure that all of job-related tasks are being performed in a correct manner while the staff member is unsupervised in the field.
When it comes to DME accreditation, surveyors receive multiple inquiries on an ongoing basis regarding how to monitor quality continuously and improve the performance of their organization.
Or ... running on the treadmill and staying in the same place fast?
Reimbursements have dropped, goods cost more, employees would like a raise and as the business owner, you are barely staying in the black. You constantly make cuts to your expenses when you can, but the situation still is less than desirable.
On August 16th the Accreditation Organizations received the notice below from CMS and we were asked to share the information with all suppliers.