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HEALTH CARE VOLUNTEER PROGRAMS

This page is devoted to the management of volunteer programs in health care settings.

~July 2009~

TIPS ON ACCREDITATION SURVEYS

Get any group of healthcare DVS’s together and before long, someone will inevitably ask a question regarding requirements for healthcare accreditation survey.  I think that the entire “aura” surrounding the accreditation process causes everyone to get weak in the knees.  While it is a good idea to keep current on accreditation requirements, if you are running a solid program with basic volunteer management processes, you should be fine when the accreditation surveyors come knocking on your door.

So what does a solid program with basic volunteer management processes entail?  Let me outline the important aspects.

  1. Departmental policies & procedures – This should be the overarching guide to the department organization, structure and process.  I believe this is the most important piece to the survey process.  It should be something formally written addressing the various processes for your department addressing how volunteers are utilized in your facility. 
  2. The intake process – Your process should be adapted to what works best for your facility but should minimally include an application, an interview to determine appropriate matching to opportunities, and limited criminal history check if your Human Resources folks run these on potential new hires.
  3. Education – Documentation is required to illustrate that the volunteers have been adequately oriented and trained on patient safety, your facility safety protocol, patient confidentiality and infection control requirements for your facility.  Education should include the first training done before volunteers get started and then annually to illustrate that they are keeping abreast of changes that may occur.  This can be easily accomplished on an annual basis with an educational booklet and checklist, web-based self study, or attendance at a workshop refresher.
  4. Supervision – Depending on your facility and what you have volunteers doing, supervision can either be centralized or decentralized.  I currently run a decentralized program which means that volunteers report to the people in the departments where they are placed.  Whatever supervisory format is in place at your facility, it should be addressed in your policies.  It’s not a bad idea to include some information for training employees to work with volunteers as well. 
  5. Evaluation – While annual evaluations are something that is a normal part of the employment process, getting them done for volunteers can be a never-ending nightmare.  And the reality is whether you do evaluations or not, you always know where the problems are.  As the DVS, you are the first one called when there is a problem with a volunteer.  If you feel it necessary to conduct annual evaluations, be sure to set up the process to be as minimally time consuming as possible.  My policy (and there is a written policy detailing expectations) is to conduct evaluations by exception only.  When I was challenged on the evaluation process by a surveyor, I simply replied that it was my departmental policy that evaluations were done by exception only.  Annual education provided the proof that volunteers were current on what they needed to know.  That answer sufficed for the surveyor.
  6. Recognition/Retention – More often than not, truly involving volunteers in the daily work of their department and your facility will provide the motivation for them to stay.  If they feel needed and valued, there is no gift or reward greater than that.  This is best done by the folks in the departments where the volunteers are placed.  Recognition awards should meet the needs of all involved based on their preferences.
  7. Discipline/termination – Once in a while, volunteers cross the line and overstep boundaries.  While this is never pleasant, it is a good idea to have the process in place for dealing with these situations.  Then if/when you are faced with this predicament, you have an objective process to deal with them in the kindest manner possible.  This illustrates to the surveyor that you have considered risk management in your process.

Knowing that you have a solid program with these aspects addressed will give you the confidence to face the surveyors should you get called in to meet with them.  Along with this confidence and the knowledge that you know you have a good program, remember to breathe as you talk with them.  Don’t let the “aura” of the accreditation process make you weak in the knees! 


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The author of the Heath Care Volunteer Programs column is Mary Kay Hood MS, Hendricks Regional Health, Danville, IN (317) 745-3556. With a BS degree in biology from Marian College and a Master of Science in Management from Indiana Wesleyan University, Mary Kay has been involved in volunteer management over twenty years with a zoo and in the health care field. During that time, she completed the Management of Volunteer Programs course offered at University of Indianapolis, several supervisory training programs as well as the Indiana Hospital and Health Association’s Management Institute offered by the Executive Education Program, School of Public and Environmental Affairs at Indiana University. Mary Kay served on the Nonprofit Training Center of United Way from 1993 to 2006. During that time, she taught many workshops also facilitating speaker arrangements for the Basic Volunteer Management series. Additionally, she has presented at various national and international conferences. Mary Kay served as president of the Central Indiana Association for Volunteer Administration (CIAVA) from 1993-1997 and the Indiana Society of Directors of Volunteer Services (ISDVS) from 2006-2008. She was also the recipient of the 1995 Outstanding Director of Volunteer Services Award and the 2002 United Way of Central Indiana Volunteer of the Year Award. Most recently she served on the Steering Committee for COVAA resulting in the formation of a new national membership organization for those in volunteer management, the Association of Leaders in Volunteer Engagement (AL!VE). With several published articles, she is also author to two books: The One Minute Answer to Volunteer Management Questions and The Volunteer Leader as Change Agent.

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