Committee Minutes

Minutes, minutes, minutes.

Throughout URAC's standards and the Program Guides, you'll find references to the need to submit committee minutes to demonstrate compliance with the intent of the standards. This is a good general rule, and it is an imperative when the standard is all about a committee.

Such is the case with URAC's Core 33, describing the requirements for your Quality Management Committee:

The organization has a quality management committee that: (Primary)

(a) Is granted authority for quality management by the organization's governing body; (Secondary)
(b) Provides on-going reporting to the organization’s governing body; (Secondary)
(c) Meets at least quarterly; (Secondary)
(d) Maintains approved minutes of all committee meetings; (Secondary)
(e) If applicable, includes at least one participating provider or receives input from a participating provider committee (such as a Physician Advisory Group); (Secondary)
(f) Provides guidance to staff on quality management priorities and projects; (Secondary)
(g) Approves the quality improvement projects to undertake; (Secondary)
(h) Monitors progress in meeting quality improvement goals; and (Secondary)
(i) Evaluates the effectiveness of the quality management program at least annually. (Primary)

The Program Guide, in my view, understates the role of QM Committee minutes when it suggests only the following documentation for the desktop review stage:

Program description and plan or P&Ps addressing QM oversight of the program.
QM program evaluation or sample meeting minutes reflecting evaluation of program effectiveness.

The demonstration of the evaluation of program effectiveness, required by subsection (i), is not the only thing your submitted minutes should reflect. Why not meet as many of these subsections' requirements as you can with your minutes? Ideally, in addition to your program documentation, you should submit QM Committee minutes from within the past year (documenting participation at that meeting of at least one participating provider) from a meeting or meetings at which the committee provided guidance to staff on quality management priorities and projects, approved the quality improvement projects to undertake, monitored progress in meeting quality improvement goals; and evaluated the effectiveness of the quality management program.

I know that's a mouthful, but my guess is that, if you're doing things correctly, you can find one or two meetings in the last year at which the QM Committee did all of these things. So, it should be no great burden to submit the minutes to the meetings along with your QM Program Description.

Core 32, which outlines the requirements for the quality management program, is quite straightforward and, on its face, easy to document:

The organization has a written description for its quality management program that: (Primary)
(a) Is approved by the organization’s governing body; (Secondary)
(b) Defines the scope, objectives, activities, and structure of the quality management program; (Secondary)
(c) Is reviewed and updated by the Quality Management Committee at least annually; (Secondary)
(d) Defines the roles and responsibilities of the Quality Management Committee; and (Secondary)
(e) Designates a member of senior management with the authority and responsibility for the overall operation of the quality management program and who serves on the Quality Management Committee. (Secondary)

The Program Guide says that all you need do at the Application stage is submit a "Program description and plan or P&Ps addressing QM oversight of the program," and your documentation worries are over.

And, for some reviewers, that may be so. However, you can save yourself the risk of a dispute over the adequacy of that documentation, and take some of the work out of the onsite review process, if you go a bit farther in demonstrating compliance with subsections (a) and (c). These subsections contemplate review and approval by specific panels, with (a) focusing on the governing body and (c) looking at the QM Committee.

At some point in the process, either during the desktop review or the onsite review, the reviewer will need to see documentation independent of the QM Program Description that the governing body has approved the QM Program Description and that the QM Committee, within the past year, has reviewed and approved it.

I recommend that you do this up front, at the Application stage of the process. This should be easy -- submit committee minutes demonstrating such committee approval by both of these panels or submit signed, dated attestations from the chairs of these to bodies indicating that their committees have, as required, approved the program document, and when each committee did so.

While I usually think the Program Guide provides the best idea of what documentation will suffice for a particular standard, this is one situation in which I think it's best to go a bit farther.