Clinical Hyperbaric Facility Accreditation – Is The Juice Worth The Squeeze?

  As many in wound care know, the field of hyperbaric medicine has grown geometrically during the past five to 10 years. In the end, this is a good thing. However, this rapid rate of growth has also produced many challenges for our community—challenges to seek qualified practitioners, maintain the highest level of patient safety, and to demand uncompromised quality of care. It is unfortunate that most newly christened hyperbaric practitioners and healthcare administrators are not aware of the October 2000 Department of Health and Human Services, Office of the Inspector General (OIG) Report titled Hyperbaric Oxygen Therapy: Its Use and Appropriateness (OEI 06-99-00090). Without going into a discussion of specific details, this assessment reported that more than $19 million (38%) of Medicare funds paid to facilities during the period from 1995 to 1998 were in error—for either inappropriate treatment and/or excessive treatment. Additional findings related to poor documentation; lack of testing and treatment monitoring raised quality of care concerns; limited guidance from the federal government; and, questions over appropriate use along with the potential for significant growth in the field were reported.

  The recommendations provided by the OIG to the Department of Health and Human Services were as follows:
    1) Initiate a more defined national coverage policy related to hyperbaric oxygen therapy.
    2) Improve policy guidance (practice guidelines and physician attendance policy).
    3) Improve oversight by requiring contractors to initiate edits and consistent medical review procedures, and to explore the possibility of establishing a registry of facilities and physicians providing hyperbaric therapy.

  If the author must point to a single event that prompted the Undersea & Hyperbaric Medical Society (UHMS) to establish our Clinical Hyperbaric Facility Accreditation Program, this would be this report. From what professionals have learned from accreditation since 2002, the report accurately portrayed the situation as it existed during the period of review. In essence, the OIG recommended to the Centers for Medicare and Medicaid Services (CMS) that oversight of hyperbaric medicine be increased. To many, this served as a wake-up call to the community that wound care professionals must take ownership of this problem and demonstrate to CMS that we are justly concerned and, more importantly, prepared to take action within our own community to improve the practice of hyperbaric medicine across this county. Who better than the wound care community to address its own problems? Therefore, hyperbaric facility accreditation was created and implemented.

  Since the first voluntary formal survey in September 2002, we have now initially surveyed 90 hyperbaric programs across the nation. At present, 83 of these are actively maintaining their accreditation. The reasons that the other seven have not been reaccredited range from revocation of status, hospitals being closed due to Hurricane Katrina, programs closing for other reasons, and several who have simply chosen not to reapply. It is unfortunate these few have elected not to reapply. It is this author’s firm belief that they are missing a tremendous opportunity to demonstrate to the patients in their catchment area that they are the best. One facility even stated that their reason for not reapplying was that they did not see any increase in patient volume after being accredited. This is surprising because this author continually receive reports from programs all over the country that are claiming increases in patient volume as high as 45% after initiating an aggressive marketing campaign to educate their referral base that they were accredited. From this, one must assume that programs claiming no increase in patient volume must not have aggressively marketed their accredited status. The author believes that expectations of increased revenue are NOT a reason to seek accreditation. Accreditation should be sought because it is the RIGHT thing to do. There are 28 facilities already scheduled to undergo survey for 2009.

  It is important to explore what measurable changes have occurred in the five-plus years of accreditation because it is here where benefit can be clearly demonstrated:

  Board certification for personnel has been stimulated:
    a. The number of nurses certified in hyperbaric nursing has increased by 49%.
    b. The number of technicians certified in hyperbaric technology has increased by 200%.

  New hyperbaric education programs have been created:
    a. Safety Director training.
    b. Acrylic window/tube inspection requirements.

  Educational level for medical, operational and safety issues has been enhanced:
    a. Minimum training standards established and expected.
    b. More than 800 Safety Directors have received specialized training.
    c. Acrylic inspection criteria, which will defer the high cost of acrylic replacement by extending the service life of the material by an additional 10 years, have been implemented.

  National safety standards have been refined as a direct result of accreditation:
    a. Since 2005, over 30 changes have been made to the primary hyperbaric safety standard, NFPA 99, Health Care Facilities, Chapter 20, Hyperbaric Facilities.
    b. Hyperbaric chamber manufacturers are now providing hospitals the documentation required by the American Society of Mechanical Engineers’ Safety Standard for Pressure Vessels for Human Occupancy (ASME PVHO-1).

  Operational safety issues have been enhanced:
    a. In-house safety training for part-time and full-time staff has been improved.
    b. Maintenance of bulk oxygen services and gas cylinder management has improved.
    c. Overall safety awareness has been raised.

  Positive impact on quality of care and patient safety has been demonstrated:
    a. Patient assessment processes have been enhanced.
    b. Patient education processes have been promoted.
    c. Quality and completeness of patient treatment documentation has dramatically improved.
    d. Quality improvement activities has moved beyond patient satisfaction surveys to meaningful, clinically relevant outcomes.
    e. Issues related to patient confidentiality, adequacy of treatment space, appropriate staffing levels have been successfully addressed following accreditation surveys.

  For programs that have aggressively marketed their accreditation, increases in patient volumes of up to 45% have been publicly reported.

  One of the objectives of our program is to become recognized by The Joint Commission as a complementary accrediting body. At present, we are at 83% of that goal. When we achieve our goal of 100 active accredited programs, we will submit our application to the Commission for recognition. If accepted, The Joint Commission will formally acknowledge UHMS surveys conducted in hospital organizations that provide this therapy and for once accept surveyors with the proper skills and understanding of the unique requirements of hyperbaric facilities.

  As many know, precedence has been set in Utah by linking Medicaid reimbursement to UHMS specific accreditation. In the future, other agencies and carriers will make reimbursement links as well. The author believes this because BCBS, Aetna, TriCare, HIP Health Plan, Harvard Pilgrim Health Care and others have contacted him to discuss accreditation. This represents a heightened level of awareness and perhaps expectation, even though these other groups have established no requirement for accreditation.

  The author frequently hears the comment that accreditation is too expensive. It is important to put the cost in perspective. The period of accreditation is three years (36 months). If you were to divide the most recently calculated average total cost of accreditation by 36, the result is approximately $185/month. Based on current CMS reimbursement rates, this represents approximately two 30-minute billable treatment cycles for one patient per month. Therefore, based on this data, UHMS accreditation is the most cost-efficient third-party consultancy that any hyperbaric program can seek. Nowhere else can a facility bring in a team of experts to offer suggestions on process improvement for this cost.

  In closing, the author trusts that he has created a level of understanding that hyperbaric facility accreditation was created specifically to address a defined need. The value of accreditation continues to be demonstrated and has proactively addressed the concerns and recommendations contained in the October 2000 OIG Report. A major milestone will have been met once Joint Commission recognition has been achieved.

  W.T. Workman, MS, CasP, CHT, FasMA, is the Director of Quality Assurance and Regulatory Affairs at the Undersea & Hyperbaric Medical Society, UHMS Satellite Office in San Antonio, Texas. For additional information on how your facility can join the growing list of accredited facilities, contact Tom Workman at (210) 404-1553 or uhmsqara@aol.com.