BHE Podcast, Episode 026 – Denise Hobson, ACHC Behavioral Health Accreditation Program Director

Denise Hobson, who serves as the Accreditation Commission for Health Care’s behavioral healthcare accreditation program, joins the BHE Podcast to discuss the latest Quality Review Edition of The Surveyor, which highlights common compliance deficiencies for behavioral healthcare facilities. Hobson highlights some of the primary causes for providers’ deficiencies, and explains how ACHC’s findings can help organizations improve their performance.

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TRANSCRIPT

Tom Valentino: Welcome to the Behavioral Healthcare Executive Podcast. We are joined today by Denise Hobson, program director for the Accreditation Commission for Healthcare’s Behavioral Health Accreditation Program. Denise, thank you for joining us.

Denise Hobson: Thank you, Tom.

Valentino: Tell us a little bit about ACHC and of the work that you do.

Hobson: Thank you, Tom. ACHC, Accreditation Commission for Healthcare, we are a nationally recognized accrediting organization while some of our programs are internationally recognized as well. I love to share that we were established in 1986 as a grassroots project from a list of industry leaders and provider organizations that really reached out to us and wanted to help develop an affordable accreditation option for providers. That just started the adoption of our motto, “For providers. By providers.” I always like to say that. To me, that carries such a meaning that we understand where the providers live and how they operate. I just like to share that. Again, we have been an accrediting organization since 1986, but I do want to share, we were so excited that in late 2020, ACHC merged with the Healthcare Facilities Accreditation Program, HFAP. That merger has allowed us to expand our opportunities across healthcare settings such as the acute care, inpatient facilities, our critical access, ambulatory surgery centers, our office-based surgery centers, clinical wise. That merger just united ACHC and HFAP to create now a continued spectrum of healthcare accreditation. We’re very excited about that.

We at ACHC, our accreditation program does offer an extensive array of focus options that are focused on that specific provider, again with our services being parallel with our customers, the care that they deliver, and the services that they offer. Also, accreditation—as I like to explain it—is truly an independent third-party validation of behavioral health organizations, as we’re speaking of today. It validates that they have qualified staff delivering the care and services that they offer and that that is based upon their service recipients, appropriate assessments, the development of the treatment plan, the execution and delivery of that services. All of that is developed and in concert with that service recipients’ needs being layout.

Valentino: You recently put out a report known as The Surveyor. Catch our listeners up on what that report is and how you put it together.

Hobson: The Surveyor is a publication of ACHC that is distributed twice a year. In our spring/summer edition, that’s a single publication that really covers all of our programs, and it offers an update of any new services or any updates to our current services or industry updates. Such as this past year, we started including some little, short pieces or excerpts of hero stories—which we’re excited about that—that simply identifies individuals within our accrediting organizations who are using the framework and the value of accreditation and demonstrating how to go over and beyond to meet the needs of their patients or their clients. Our fall edition, most recently, that’s a series of separate publications that’s focused on an individual program, such as behavioral health, will have its own edition of The Surveyor. What this does is it helps us to focus and highlight that program and events included in that, such as our most frequently cited deficiencies or better known as the top ten list of deficiencies, if you will, over the specific past time period of the year.

We also take that to our providers in that publication, and we offer them tips for compliance. We tell them, as an industry, what those top deficiencies that we’re seeing cited, and then we take them to the next step of tips for compliance. Again, this is just to ensure their education and their continued compliance. I like to share, Tom, that often it’s not that an organization is completely missing the requirement. That deficiency is cited as all inclusively, but it may just be that there’s just one component of that standard or requirement that’s missing. That’s what we like to highlight when we offer the education and feedback to our provider customers.

Valentino: In your research, then, what were the most common deficiencies that you’re seeing?

Hobson: I want to share with you again before I talk about the deficiencies, the time period in this report. This covers a period from the first of June of 2020 through May of 2021. For a second time, I want to share the top three to four because three and four were top for the percent of time cited. The first one, the top No. 1 most frequently cited, which was 30% of the time, was standard BH2-6A. That is a requirement that’s related to an organization having policies and procedures related to securing and releasing confidential and protected health information. We all understand the importance of that. Again, this standard was cited because of there being missing elements of either the organization’s policy or their procedure related to confidential and protected health information.

For example, some of the surveyors’ actual findings were that they did not have evidence that the service recipient and/or their responsible person received and understood the information related to confidentiality prior to receiving the services. Another example is that the organization did not have evidence of a signed release of information when billing a third-party vendor that shares that information of that service recipient.

A quick tip of mine for compliance is just assigning responsibility. If it’s in the personnel file that they didn’t sign their confidentiality statement, assign that to your HR manager, and part of the chart audit for the personnel records. That was the No. 1 for this period of time.

The No. 2 deficiency that was cited is BH4-4A. We’ve seen that 26% of the time. That standard and the overview of that requirement is that the organization must provide and document an orientation process for all their personnel. Simply said, the standard that was cited was simply when organizations did not provide that they had a comprehensive orientation program. That could be all of the orientation plan not being developed and comprehensive, or it could be a portion of it. There was no evidence of an orientation with all required elements. There may have been 1 or 2 things missing, but they had others. Based on the requirements in the standard, it was not met a 100% of the time. A tip for that is establishing an orientation process that you can go through the standards and the requirements and determine that all of those topics are included in your orientation program.

No. 3—I’m going to say the first No. 3 because we did have a tie for 20% of the most frequently cited—was BH4-2C. This was related to the organization having policies and procedures to provide all direct-care staff. Now, direct-care staff with a hepatitis vaccine. That was cited 20% of the time. This is where our Surveyor cited it when organizations did not appropriately or comprehensively establish a policy and implement it related to the hepatitis vaccine just for the direct-care staff.

Some of the things we would see is that they may have it, but, in a personnel file. We didn’t see that they had either received it or signed a declination that they had it. It could be all was missing, or a portion of that component was missing. Tips for that is just establish your policy that you have for hepatitis vaccine and the process, and that you audit for that to make sure that you have that in place.

The other number—we’ll call it No. 4, even though it tied for No. 3—is 42BH42-G. That was related to the background checks when we do our personnel file audits. Then, this is a standard that ensures that background checks are completed on personnel that have direct-care responsibilities to those service recipients and/or they have access to their records. This was cited 20% of the time. It was either all or a portion of that was missing. Examples of real findings were that the organization did not include written policies and procedures regarding their background checks. They didn’t have a policy defining that in the process. The other example could be that assign responsibility to complete that background check and making sure that that carried over into the personnel direct-care staff or appropriate staff personnel file. That it was actually completed and validated that it was conducted. Just some examples.

Those I will say were the top 4 standards that were frequently cited from our surveyors. I just want to stress that it’s a combination that either all of it was missing or just a portion of it was missing. The beauty of that is the results of the survey—the summary findings—will explain that.

Valentino: Did you find that those common deficiencies were consistent with past reports that you’ve put out? Were there any of those that became more common issues this time around?

Hobson: No, we didn’t see anything that was a great surprise, like a new event. I guess you could look at that time as a good thing and a bad thing. We just stress to our organizations, our customers, one of the things we do is offer them an items needed for preparing for survey, that lists all the standards, any document, a policy, anything that will need to be in place for them to prepare for the survey. We stress to them, use this as your self-audit tool. Then, in mid-cycle, we have a 12 and a 24-month compliance checklist that they can use that also because our surveys for our accreditations are for 36 months.

Then, we recommend that mid-cycle that they do these self-audits, put it in place, assign it to. The personal file may be your HR manager’s responsibility. Your performance improvement may be assigned to your clinical director or someone. Covering all the bases as a collaborative approach.

Valentino: Have providers given you any indication as to what might be the root cause of some of the challenges they have with compliance? For example, this year that you had covered. This report was basically the first year of the pandemic. Was that a contributing factor? Were there staffing issues that make some of these things more difficult? Other issues as well?

Hobson: Tom, that is a wonderful question, and I think you’re already spot-on for my response, is yes. With this time period being in the initial phase, and the peak of the pandemic, staff turnover in all healthcare industries—really any industry, but we’re seeing it in the healthcare—and behavioral health is included in that. Staff turnover, whether it’s they left, and that means we have new staff members that are not as to the level of their understanding of the survey preparations and the standards’ interpretations. Also, let’s say not just staff turnover, just staff limitations related to COVID, some decrease in staff and the services.

Really having to put the priority on serving those recipients’ needs in a very unique and creative way, such as telehealth. That’s another thing for behavioral health that we’ve seen really explode, and that’s why we’ve opened opportunities for a distinction in behavioral health with telehealth.

Staffing, for sure, I would put that up there at No. 1. When I also think about it, it’s truly the global. What most consistent evidence that we do see is really the lack of deep down diving into the standards and understanding them.

Reaching out to ACHC for those clarifications, really organizing your organization so that you have dedicated staff focusing on their area of expertise or their assigned area, whether it be performance improvement, service delivery, record management. Really, just having a very orchestrated approach to the survey, not just to prepare and achieve it, but to sustain it and maintain compliance during that cycle.

Valentino: The dialogue that you’re having with providers. It seems like there’s a really great opportunity here to use these results that you’re providing as a benchmark which can help lead to performance improvement, which, ultimately, I think is the goal for why a provider organization would want to go down this path in the first place.

Hobson: Absolutely. Tom, one of the things that I always like to share is that, whether it’s behavioral health or any other service industry, an accreditation it’s really trying to explain and hopefully sell the value of accreditation. The value of accreditation is when you see a provider organization that truly, truly embraces the concept of accreditation. What they do is they focus even deeper onto data-driven outcome measures, evidence-based information that says—from any industry as well as even themselves—these are the areas that we’re seeing trends identified or these are areas where we know that we need to improve upon. It’s either self-identifying or taking what we just shared today and comparing yourself to peers.

Looking at it, one of the things we do, Tom, is we not only share this information with our providers and our customers but also our surveyors in our team and educating them on the top 10 deficiencies and making them aware because that paints a global picture versus just one organization, one surveyor.

It truly takes this opportunity to help providers embrace the concept of continuous quality improvement. You can’t do that if you don’t have back data and evidence that you can benchmark and see where those improvements are occurring, where those areas that are either internally or if they’re appear related, or if it’s industry-related. You’re absolutely correct on that.

Valentino: Denise Hobson, ACHC Behavioral Health Accreditation program director. Thank you so much for taking the time to join us. This has been fun.

Hobson: Thank you, Tom. Thank you so much and thank you to all of our behavioral health providers that have such a challenging expectation in these times of pandemic. Creativity, we’ll call it.

Valentino: Good stuff. All right, folks. As a reminder, you can subscribe to the Behavioral Healthcare Executive Podcast on Apple Podcasts. Past episodes are also available on our website behavioral.net. That’s going to do it for this episode. Our thanks once again to Denise Hobson. I’m Tom Valentino and this has been the Behavioral Healthcare Executive Podcast.