Recipes for success from the best of the best
Recipes for success from the best of the best
How can you be accredited with commendation?
Editor’s Note: Just what does it take to sail through your Joint Commission survey? What do agencies that become accredited with commendation have that you don’t? In the first of a series, Homecare Quality Management asks for pointers from such agencies.
When Bill Houston, MBA, CHE, took over as executive director at CDM Home Heath Services in Vancouver, WA, four years ago, he inherited an agency with few written policies and procedures. Those that did exist were hopelessly outdated.
But with 22 years of hospital and rehabilitation experience, Houston knew that by applying standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) of Oakbrook Terrace, IL, he could whip the agency into shape.
"I knew that JCAHO accreditation was a tool that could push us to fix our problems," he recalls.
It took about two years, but the program paid off last December when CDM went through its first survey and was not only accredited but accredited with commendation.
His first step was to put together a team to oversee survey preparation. Led by the systems manager, it included the director of human resources, the director of services, accounting personnel, line staff members, and supervisors. Houston largely stayed out of the meetings. "I just popped in and out. My job was to light the fuse for them."
The team had to set goals, divvy up the JCAHO standards manual, and figure out just where the agency stood, Houston says. Where it stood was in a mess.
"When I came here, I found out we were paying overtime based on 160 hours a month, not 40 hours a week. That wasn’t in line with the Fair Labor Standards Act," he says. The orientation package for staff was limited and had no emphasis on quality of care. There was a lack of communication and training among the 270 employees and supervisors.
In the course of two years, the team worked out policies and procedures, developed a quality assurance program and tried to see that everything was in line with the JCAHO standards manual.
Houston and the supervisory staff emphasized the importance of the survey to the field workers and administrative support.
"We made this a challenge to the whole agency," he says. "We had hats and T-shirts made up. We involved absolutely everyone, because you can have a whole ton of good work reversed by one employee."
Houston says one reason the team was successful in preparing for the survey was that it constantly communicated.
"We cut the manual up into chewable chunks," he recalls. "Then at the JCAHO player meetings, everyone knew what everyone else was doing. We knew that if one person didn’t know the answer to a question, there was someone else on the team who did. And we knew who that person was."
Expensive, but worth it
Once the initial work was done, the agency booked a JCAHO surveyor to come do a mock survey about three months before the real survey was due. This, says Houston, was a watershed for the agency.
While it was an expensive proposition, he says, it pointed out some errors the agency wasn’t aware it was making. For example, medical releases for staff were being kept in employee files.
"We didn’t know we had to keep them in separate files," recalls Elysia Herz, director of services at CDM. "That was a big surprise to us, and made a real difference in the survey."
If you are going through a survey for the first time, she advises, "don’t even attempt it without going through a mock survey first. It’s worth every nickel."
Three months later, the agency went through the real thing. Herz says it was often the little things that seemed to make a difference to the surveyor. For example, the agency prepared about a dozen notebooks with required materials separated and organized.
"We had one for marketing, one for the on-call supervisors’ notes," she says. "It sounds cosmetic, but it took the surveyor less time to find what she wanted to see."
Staff were also instructed to be available for the surveyor. To facilitate that, the agency provided lunch so that all employees were on site when required, says Herz.
The commendation wasn’t a done deal, Houston says. In one human resources area, the agency was marked down. Herz recalls that the surveyor said that performance appraisals didn’t match job descriptions.
"But then we pulled them out and compared them," she says. "That decision was reversed."
The lesson, says Herz, is that you shouldn’t be afraid to question a decision made by a surveyor. "There were a couple things that weren’t readily apparent to her that we were able to clarify."
The outcome was a bonus
While the commendation is a bonus, Herz says — and Houston agrees, even if the agency had not even been accredited, the whole process was beneficial.
"There was so much information that we just kept in our heads. For two years while we prepared for the survey, we put our policies and procedures down on paper. We created an employee manual. And now we have a mechanism for updating these regularly. That makes all of the time and money spent worth it."
Currently, policies and procedures are on a two-year cycle — meaning that every one will be reviewed at least once every two years. But that depends, says Houston, on the particular policy or procedure, and whether there are any regulatory changes in the interim. Each department is responsible for going over the policies that are relevant to it, he adds.
The next time CDM goes through survey, the surveyor will see continued changes and improvements.
"It’s hard, when your staff are out in the field, to make time for education," Herz says. "We really struggled with that. But I think we recognize we have to have more education for everyone — from our office staff to our field workers. We have to make sure they understand all our policies and procedures. Even though we came out fine in this area, we know we have to have more and better information going out."
The agency already held monthly district meetings between supervisors and staff, and bimonthly meetings of the entire staff.
But the format and content of those meetings have changed. Houston spends more time updating staff on rules and regulations, policies, and procedures. The meetings of the entire staff include important topics, such as death and dying, or depression in the elderly.
"We repeat them often," says Houston, "and I also talk about political issues and try to keep staff politically aware and active."
The whole JCAHO program cost CDM about $10,000, says Houston. Along with the pride of having passed the first test with flying colors, he thinks the commendation will give the agency a good marketing tool.
An added benefit is that a successful JCAHO survey provides the agency with deemed status in Washington state for one inspection. And the process of getting the policies and procedures updated and down on paper gave employees a tangible target and a new sense of purpose.
"We all want to be the best at what we do — the best service provider, the best employer," he says. "This fell into place with the philosophy of our board of directors. It got me new policies and procedures, and a quality assurance measurement process.
"But mostly, it was a morale booster. The people here knew it was a hard job. For the first time, they were part of a team process that was something more than just putting on a Christmas party for our clients."
Sources
• Bill Houston, MBA, CHE, Executive Director, and Elysia Herz, Director of Services, CDM Home Care Services, 8100 N.E. Parkway Drive, Suite 175, Vancouver, WA 98662. Telephone: (360) 896-9695.
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