Concern ~ Focus ~ Purpose
Who's Who in Your Organization

Geoffrey Krueger, BA, RRT, RCP
Proactive Solutions HME Consulting LLC 

If I had to quickly summarize what accreditors are interested in assessing about your organization, it would be something like: They are looking to see WHAT you do, HOW you do it, and WHO is doing it.  It's the last part that we'll spend a little time on here, with emphasis on a review of the documentation aspect.


An organizational chart is simply a graphic representation of a group hierarchy.  There are a number of formats in common use, but of main importance is that your chart accurately represents:

  • Every ownership, management, and staff position/job/title within the organization (including contracted)
  • The lines of supervision/reporting between and among positions
  • Positions such as Compliance Officer, Privacy Officer, Performance Improvement Coordinator, Safety Officer, Infection Control Officer, etc., as applicable
  • Governing Body, as applicable
  • Professional Advisory Committee, as applicable

Of course, in smaller organizations there will sometimes be one or more individuals who hold more than one position or title.  Just make sure that these are designated on the chart.  Post the organizational chart where it is easily viewable by staff members and update as necessary (include the most recent date of revision on the chart).

If your organization has more than one location, ensure that your organizational chart specifies reporting hierarchies by location.  This can be accomplished using a single "master" chart, by separate location charts or a combination of both.

For each and every position/job/title on your organizational chart, you must also have a written job description, and vice-versa.  Job descriptions must include:

  • Position Title
  • Job Duties
  • Reporting/Supervision Responsibilities, as applicable
  • Minimum job qualifications, experience requirements, education, and training
  • Requirements for the job
  • Physical and environmental requirements with or without reasonable accommodation 
  • Date of most recent review/revison of the job description

Documentation that the individual has read and acknowledges receipt and understanding of their job description(s) can be accomplished by the individual's dated signature on the job description itself or on some other statement that verifies their receipt and understanding of it.  Copies of the signed job description(s) and/or statement should be maintained in the personnel record.  Simply placing an unsigned job description in the employee file is NOT, of itself, adequate evidence of receipt and understanding by the employee.  The job description should be reviewed with the employee as part of initial orientation, annually with job performance evaluations, and as changes are required and implemented.

Just from my own anecdotal experience, I have noticed a couple of things that deserve mention:

  • Job descriptions for Fitters of mastectomy and other prosthetic/orthotic products are the most common to be missing.  Sometimes the components of the Fitter position are incorporated into another job description, e.g., Customer Service Representative, and that is fine, however, there must be a delineation of this position in some form, either combined or separate.

  • Job descriptions for Respiratory Care Practitioners are sometimes found to include clinical procedures that are not part of the RCP's function within the organization.  While it is true that a licensed RCP may perform certain clinical ("hands-on") procedures with proper physician approval, if the organization does not provide Clinical Respiratory Care Services, these functions are more appropriately excluded from these job descriptions.  For further guidance on what constitutes Clinical Respiratory Care Services, consult with your accreditor. 

  • The job description(s) for the individual(s) designated as being responsible for assuming the duites of the organization's leader in the event of temporary absences or vacancies must include these delegated duties.

By reviewing your organizational chart and job descriptions on an ongoing basis (at least annually), you will be more likely to avoid several related deficiencies on your next accreditation survey.


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