Eye on Accreditation: Sandra Canally, President, The Compliance Team

How does your organization differ from other deemed accrediting organizations?
We’re the only for-profit, privately owned accrediting body to ever be approved by CMS. The reason I mention that is because I’m a small business owner just like the provider. Our emphasis is in working with a small business. The other thing is that we have the only all-inclusive program. When providers sign up with us, the first thing that’s going to happen is they’re going to receive a preparation CD that includes such things as self-assessment checklists, all necessary policies, forms, etc. There’s no need to buy a policy and procedure manual or hire an outside consultant because we work with them to help them through the process. The next thing that happens is they’re assigned an adviser. That adviser through scheduled conference calls actually takes them through the process. For instance, today we’re going to talk about HR; this is what you need to have in your personnel file. We actually take them step by step in small digestible chunks. It’s not nearly as overwhelming as if they received a big manual, no guidance, and ‘OK, this is your deadline. Figure it out.’ They can call us as much as they need to in between times.

How long does it typically take for a respiratory provider to become accredited with your organization?
If you’re talking one site and not a chain, it usually takes an average of four months, and that’s with us looking at three months compliance history. It takes an average of four hours a week to implement our program.

By breaking it down through these conference calls, what we do is we give them homework in between. When you take it one step at a time, it’s a whole lot easier. By the time they’re done, they don’t realize they’ve done as much as they’ve done.

What common pitfalls have you seen respiratory providers face when they’re undergoing accreditation?
The major issue across the board is documentation. Documentation is certainly necessary because it protects the company. When you can explain to the provider that by doing these things, if something happened, you could see where this would protect you by showing how your staff is properly trained, how the patient has been properly educated. It makes all the difference in the world because it makes sense to them; it’s logical. They can see where, operationally, it’s easy enough to implement into everyday operations.

What is typically the easiest part of accreditation for respiratory providers?
The majority of respiratory providers really do have a handle on (equipment) tracking. They typically do a good job with checking the concentrators and all of those things. Sometimes they run into difficulty with tracking the tanks, but most oxygen providers know where the concentrators are. Most providers that I’ve worked with have a good understanding of the use of oxygen, what to avoid, how to properly store it, and care of the concentrator, as well as how the patient needs to be educated as it relates to that. Certainly the number one thing in the oxygen provider’s mind is serving the patient. Even very small providers know that they’re available 24 hours a day, seven days a week and that is uppermost important in their businesses.

What factors should respiratory providers consider when looking for an accrediting organization?
They need to choose an accreditor that is going to fit into their culture. We look at our relationship as a partnership with our customers. One of the other things that we do differently is that we evaluate our customers annually on-site. (Everybody else is out there once every three years.) The reason we do that is to help the provider stay on track. We require more follow-up calls with patients than the other accreditors. All of our customers have to follow up within 72 hours after the initial setup. We require that because our accredited providers are exemplary providers. In order to get accredited by us, they need to score 90 percent or better, so that they can use that as a form of quality recognition branding to set them apart from others that are not going the extra mile to be evaluated yearly, to do extra follow-up, to submit data for aggregation.

What advice would you give respiratory providers about the on-site visit?

We’re coming in to verify and validate that they meet the standards but at the same time to give them assistance as it relates to ideas for improvement, recommendations for improvement and so forth. It’s not a punitive thing. We’re not coming in to inspect and look for all the wrongdoing. We’re looking for what they’ve done right. We go in after spending four months or five months on the phone with them expecting to see good things because the relationship has already been established.

This article originally appeared in the Respiratory Management April 2008 issue of HME Business.

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