ADA compliance: it's more than 'removing barriers': complying with the Americans With Disabilities Act is a broader management challenge than you might think.

The Americans With Disabilities Act (ADA) has been around for more than ten years; yet, there has been a recent push to enforce compliance. Why is ADA compliance important for healthcare institutions? Because entities that receive federal funds--known as Title II entities, which include skilled nursing facilities receiving Medicare and Medicaid, hospitals, colleges, universities, and state and local governments--were required by law to complete a Self-Evaluation and Transition Plan by January 26, 1992, to achieve accessibility and eliminate discriminatory practices. These plans should be monitored continuously to bring their existing and future programs into compliance. It is important not to treat them as a set of binders on the shelf.

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Why? The ADA law and its enforcement are complaint-driven, so Title II entities are subject to investigation at any time to resolve complaints. One of the first questions asked by investigators will be about the existence of an up-to-date Self-Evaluation and Transition Plan--and the lack of an answer is no defense. Because facilities and their programs change over time, often the required mitigation demands the creation of a new Self-Evaluation and Transition Plan.

The law requires a series of steps to establish the framework for eliminating program discrimination, including:

1. Designating a responsible employee as ADA Coordinator. This individual is the center of activity between programs, facilities, and users, and is responsible for the facility's immediate and long-range responses to program access issues. This person cannot be just another title tagged to an existing position. It should be someone who has developed knowledge of the law and is familiar with the facility's programs, whether it be an assistant administrator, a risk manager, or someone else.

2. Providing notice of ADA requirements. After a lawsuit, the Title II entity must notify potential users of the facility of the ADA's requirements. Typical methods are newspapers. When a Self-Evaluation and Transition Plan is completed, the public must be notified that the document and findings exist and are available for review.

3. Establishing a Grievance Policy. The entity must have a process in place that allows users to state grievances, and a method of responding to those complaints. The ADA Coordinator and the Risk Manager will lead the effort in creating this process.

4. Conducting a Self-Evaluation. Discriminatory activities can involve caregiving staff and other personnel, information dissemination practices, requirements for participation, and the facility's physical attributes--e.g., corridors, dining spaces, communications systems--on general access. Other possible areas where discrimination can occur include meetings, picnics, seminar attendance, training sessions and educational activities, access to vendor products/services, such as food service or vending machines, and travel arrangements.

5. Creating a Transition Plan. The Transition Plan addresses architectural attributes of a facility, and is the result of the Self-Evaluation. Identifying architectural barriers is necessary and their removal is required when the program itself cannot be revised to provide accessibility. The removal of physical barriers should be the last resort, however, unless it is the most effective and efficient way to provide access.

Overemphasizing Architecture

More often than not, a facility will focus on the built environment to address Title II barriers and provide mitigation, but renovations should be done in a logical and cost-effective manner that provides the most "bang for the buck." This can only be accomplished by coordinating schedules, budgets, and program evaluations. The rush to make revisions and remove barriers in a broad-brush manner is neither cost-effective nor efficient. The Title II entity will likely spend more than is necessary and will use funds that could have been spent on the removal of more significance having greater impact across multiple programs.

Frequently, barrier removal on a department-by-department basis does not remove the barriers that contribute to discrimination. It is often simply an effort to do something without taking the time or effort to focus on the big picture. Accessibility demands a wide range of coordinated efforts on many fronts to eliminate discrimination.

Steps to Compliance

The following steps will help a healthcare facility through the compliance process:

* A Self-Evaluation is a process that reviews how services and activities are provided at a facility. Areas of possible discrimination such as staff attitude and responses to requests, lack of auxiliary aides and services, specific staff and personnel training, vendors' attitudes or practices, conduct of offsite activities, and all other program elements are reviewed and analyzed for access.

It is very important at this point to interview the correct person for each program. This might not be the head of the department or the designated responsible person; often it is the person involved with the day-to-day delivery of services and activities.

It is also important to review facility activities involving remote locations that are usually not reviewed for accessibility. Discrimination will occur if the parking, accessible routes, and locations do not permit access by all participants. Typical sites can include conference centers, large outdoor spaces, shopping centers, and malls.

* Transition Plans identify architectural barriers as contributors to program discrimination. For compliance, Title II entities will generate a Transition Plan documenting any facility barriers, as well as schedules and budgets for their removal. Remember, the depth of that plan is tempered by the facility's Self-Evaluation. The barriers identified might not all have to be removed. Discrimination has to do with delivery of services and activities, as well as existing methods and attitudes. The evaluation of methods and attitudes reveals possible areas of discrimination and whether there is an impact by the built environment. Program delivery, while reliant on the built environment, does not require physical barriers to discriminate, and often can be mitigated without addressing them. The Transition Plan, in its completed form, must incorporate the Self-Evaluation and those physical barriers that must be removed. There are alternate approaches to barrier removal.

* Renovations and barrier removal in healthcare facilities cannot have a separate schedule or budget from the programmatic element. Because programs might simply be revised to eliminate the discrimination, the emphasis on physical barrier removal often results in duplication of effort and wasted time and money. For example, an activity for which the facility might pose access problems might be replaced by a more accessible activity, rather than attempting to renovate the facility to accommodate it.

The process of becoming compliant is meant to be an ongoing one that can be adjusted to coincide with the entity's changing budgets and schedules. The "global" plan must be flexible and responsive to changes and conditions. In many cases, the revisions required cannot be anticipated until there are programmatic changes in the delivery of services and activities. The initial evaluation will provide the benchmark for mitigation.

All Disabilities Must Be Covered

Addressing discrimination against mobility-related physical disabilities is only one piece of the compliance process. Other disabilities must also be accounted for, including disabilities in hearing or vision, cognitive impairment, and any other disabilities recognized by the ADA.

The essential point is this: The cross-section of disabilities and the infinite variety of programs and their requirements place the weight of the law on the programmatic element. The process of Self-Evaluation for this can take as long as eight months, depending on issues such as the number of programs and the scale of the entity. While it is helpful to have someone on staff who is familiar with ADA requirements, such as an ADA Coordinator, it is important to work with a professional who understands the process and the results of ADA investigations. The Title II entity will then understand all the issues involved and be in a strong position to review the program requirements from an informed perspective.

BY DON HANKS, AIA 

Don Hanks, AIA, is founding principal of BFE Architecture, PLLC. The firm provides accessible design consulting at all stages of construction planning, product development, and evaluation, as well as access surveys and reports for barrier identification and mitigation, architectural services, and training. For further information, contact [e-mail]. To comment on this article, please send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].