Management Tips

What will the URAC reviewers find when they pull a random sample of your employees' personnel files? What should they find?

The URAC standards are rife with requirements that are likely to be evidenced in your personnel files. Because these standards are scattered throughout the Core module, it may not be immediately apparent what a URAC applicant should have in its personnel files.

Here's a short list, taken from an actual URAC onsite review agenda one of our clients just received from URAC, rearranged for clarity's sake:

• Evidence of Training
• Conflict of Interest Training
• Education on URAC Standards
• Continuing Education
• Orientation to job
• Staff Confidentiality Statements
• Regulatory Training
• Fraud & Abuse Training
• Other documentary requirements
• Annual Performance Review Process
• Job description/qualification evaluation
• Special requirements for clinical staff
• Scope of Practice Attestations
• License verification
• Certification verification

Particularly if your organization is a first-time applicant, you may be realizing that your personnel files don't have all these documents. What do you do now?

We recommend this four-step approach:

• Conduct a thorough initial assessment. How bad is it? Take a random sample of your employee files and run down the above list for each one. Using this list to perform a gap analysis that will let you know the difference between what you have and what you need to have by the time the reviewers arrive.
• Look for alternative sources of information. Now that you know what you need, find out whether you have that information, but not in the personnel files. For example, if your company has a centralized training tracking function, you may be able to take care of demonstrating compliance with all or most of the training documentation requirements through that tracking function.
• Make a plan. With those items that are neither in the personnel files nor in a centralized function, you need to make a written plan, with specific time lines (that end before the reviewers arrive!), for pulling your files into compliance with the URAC standards. The discipline of going through such an exercise will be necessary, as may be the assistance of temporary help if your staff doesn't have the capacity to handle this task.
• Look to the future. Once you have your personnel files in order and compliant with the URAC standards, make sure your policies and procedures are written in such a way to keep those files up-to-date. It will do no good to get the files into compliance this year if, for example, you are not doing annual performance reviews for all your employees and getting the results of those reviews into your personnel files.

Well-kept personnel files will help you meet the requirements of a significant number of important Core standards. Getting them into compliance may take some time, so start now.

The Basics

This short standard requires that your organization have a mechanism to collect information about your consumers' satisfaction.

This often is done in the form of customer satisfaction surveys, consumer complaints, and sometimes even focus groups.  Find out what your organization does -- it's likely more than one mechanism.

Management Tips

It is not merely important that you collect information about consumer satisfaction.  URAC typically looks for evidence that this process is built right into your operations.  This means that you have P&Ps that address this issue.  It also might mean that you use multiple mechanisms to collect this information.  

Perhaps as important as the fact that you collect this information is that you do something with it.  Make sure reports regarding consumer satisfaction regularly go to your quality management committee, and that the committee minutes reflect that.  Data alone are pretty useless -- make sure you document that your organization does something with those data.

URAC Accreditation Tips

This standard has a weight of 3.

For your AccreditNet submission, present both your P&Ps or program description that describe your consumer satisfaction data collection mechanisms and evidence that you've implemented those policies.  That evidence will come in the form of sample survey reports or tracking and trending reports of consumer complaints.

During the onsite review, the URAC reviewer will examine QM committee minutes for evidence that the committee receives the appropriate reports on consumer satisfaction.  Additionally, management personnel will have an opportunity to discuss consumer satisfaction with the reviewer.

The Basics

One of the most important of the URAC standards is this one, which requires that the organization have processes to respond quickly to urgent situations that threaten consumers' well-being.

Even though the standard speaks of "a mechanism", the reality is that it requires a system of mechanisms dealing with the full array of urgent situations that are likely to confront the applicant. You can see this intent reflected in the Program Guide under the "Evidence for Desktop Review" section:

Policies and procedures regarding responses to consumer safety address suicide, domestic violence, accessing emergency services for members, addressing significant reportable events, quality of care concerns.

What this means for the average employee is that you need to know what to do in the event you come into possession of information that consumers' health or welfare are threatened.  Your organization's P&Ps should provide you with that information -- if not, talk to a supervisor about this issue.

A particularly important issue -- one that is likely to be raised by a URAC reviewer if he/she should happen to talk to you about this standard -- is what happens when a consumer threatens suicide.  Your organization likely has a policy on this topic, so be sure you're familiar with it.

Management Tips

Your P&Ps should address the full array of likely issues.  Brainstorm with your colleagues about all the possible emergencies that could arise for consumers, and how your staff members might come into possession of that information.

URAC has a very specific notion of what is required of protocols for handling potentially suicidal callers.

Of course, as I’ve noted above, URAC expects a comprehensive system of mechanisms to respond to a wide variety of urgent situations that threaten consumers. However, it appears that, to the extent a URAC applicant has a specific mechanism regarding suicide, URAC requires that the applicant use national standards regarding handling suicide calls when it develops that policy.

Our source for this is a recent URAC desktop review summary that one of our readers sent us for review. Citing the American Foundation for Suicide Prevention’s publication, Facts About Suicide, as well as publications from Suicide Awareness Voices of Education and the National Quality Forum, the URAC reviewer commented that, “ At a minimum, this policy and process must include the process where any staff member, who has the potential to receive a consumer telephone call, can obtain a real-time assistance from another staff number while NOT hanging up, transferring, or putting on hold the caller.”

However, the tricky part of passing this standard is not so much knowing what to submit with the application, but making sure your staff members know what the basic standards of care for each of these urgent situations is.

The upshot of this is that your staff training should include appropriate responses to urgent situations. The URAC reviewers will pose a series of hypotheticals to your staff members, and will listen carefully to their answers to detect the quality of your training.

URAC Accreditation Tips

The standard is a mandatory standard. In other words, you mess up this standard and you cannot achieve full accreditation.

In the application, make sure to submit P&Ps that address the full array of likely issues.

To prepare for the onsite review, make sure everybody on your staff (and we mean everybody) can answer the question, "what kinds of situations might arise in your position in which you learn that consumers are in danger, and what would you do in such circumstances?"

The Basics

This standard requires that your organization implements a mechanism to inform consumers of rights and responsibilities relating to your services.  That mechanism should include specific guidelines for how and when the organization will advise consumers of those rights.  As a member of the staff, it will be incumbent upon you to know what your organization's policies and timelines contemplate regarding this notice.  

Management Tips

As you develop your policies and procedures around this, you have a good deal of flexibility.  URAC as a general preference, expressed in other standards, for multi-modal communications.  So, you may want to consider website, regular mail, or e-mail as modes of communication.

This standard will not apply the organization if you have no interface with any consumers.

URAC Accreditation Tips

This standard has a weight of 4.

For the desktop review phase, submit your policies and procedures describing your modes of distributing consumer rights and responsibilities.  In addition, you can submit sample newsletters or screenshots of Web pages.

During the on-site review, the reviewer will examine your documentation demonstrating that you've implemented these policies.  Furthermore, he/she will interview members of your staff who are involved in communicating with consumers.

The Basics

This standard requires that your organization have effective mechanisms to promote collaboration and communication with external organizations in order to coordinate health services of your consumers.  This might look like sharing applicable information with contracted vendors, community agencies, etc. Not all of your clients may allow you to do this, so you only be required to have this process where you have permission.

Management Tips

We recommend that you develop policies and procedures that guide your interaction with contracted vendors and community agencies.

URAC Accreditation Tips

This standard carries a weight of only 1.

For the desktop review, you need submit only your policies and procedures describing how you share information and coordinate care with external entities.

During the on-site review, the reviewer will keep an eye out and his/her review of case documentation for examples of coordination with external entities.  In addition, he/she might ask members of the staff to talk about coordination processes.

The Basics

This standard spells out requirements for your organization's formal process to handle consumer complaints and appeals.  That process must include:

• a system that provides for a prompt response to complaints
• notice of final resolution with an explanation
• a means to let consumers know how to appeal those decisions
• documentation that the organization is meeting its time frames for resolution of complaints
• a mechanism to report to the organization's QM committee on complaints and appeals.

This standard is comprehensive in the sense that it addresses all expressions of dissatisfaction with the organization's performance.  So, what employees need to know is that, if your organization is compliant with this standard, every employee who receives a complaint has a corresponding P&P that describes what should be done with that.  If you are an employee and don't know what to do with a complaint, look at your P&Ps to make sure you've got the procedure down pat.  If you look and find that your organization doesn't have a P&P that fits you or your situation, bring that to someone's attention so that an appropriate P&P can be developed to handle it.  Remember -- URAC requires that you have some sort of process for every expression of dissatisfaction.

Management Tips

The question I get most often from my clients about these standards is this: "Does this create appeal rights for all complaints?"

The answer is, "no". The standards are careful to use the phrases "if available" and "when appropriate" when referring to appeal rights. Other URAC standards do grant very specific appeal rights, but not these.

No, these standards simply explain that you must have a system for responding promptly to all complaints, and where you do offer appeal rights, that it be formal, including written notice of final determination, notification of the process for appeal, and reasonable time for resolution. And, don't forget to report periodically to the quality committee!

If you say you have no complaints, URAC's view, articulated at a recent education seminar, is that your employees probably don't know what a complaint is.  URAC's definition is broad: "An expression of dissatisfaction regarding the organization’s products or services."  With a definition that broad, URAC's thinking goes, you should have some complaints in your tracking system.

URAC Accreditation Tips

One of the elements is mandatory; the other four are weighted 4 or 3.

For the desktop review, submit all P&Ps and program descriptions that describe your mechanism(s) for handling complaints and appeals.  Also, make sure you submit a report from your complaint tracking system(s).  URAC will need to see that you have a way of not only capturing and handling all complaints, but for tracking and trending those complaints so that, when you report them to the QM committee, that committee will be empowered to take action to address systemic concerns identified by those complaints.  Also, any mechanisms for notifying consumers of appeal rights (template letters, telephone scripts) also should be part of your AccreditNet submission.

The onsite review will require that you provide reviewers with the complaint log.  The reviewer will select complaints from that log to examine how your organization handled the complaint, to make sure that you did so in compliance with your own P&Ps.  Also, everybody involved with the complaint and appeals system(s) will need to be conversant in your P&Ps on the topic.  Remember -- compliance with your own P&Ps is the most important component of this set of standards.

The Basics

This standard requires that the organization ensure access to services covered by the accreditation.

Typically, this might include familiar call-center standards for organizations that have that function.  Employees involved in meeting those standards should know what the organization's standards are and how performance is measured.

The standard does not refer only to network adequacy come but also includes all services.

Management Tips

This is a general standard that is fleshed out in further detail in other standards within this module and other modules.  Taken together, you'll need to submit some sort of access documentation in addition to the network adequacy you'll be submitting under the applicable Pharm DC standards.  Telephone statistics are a good "go-to" for nearly all URAC applicants under this standard.   URAC explains: "Many programs use telephone statistics to measure access to program services.  After establishing acceptable standards, measurements are periodically taken to ensure consumer and client access to services. Access standards related to telephone services should include standards regarding returning or responding to after hours calls and/or voice messages."

URAC Accreditation Tips

This standard is mandatory.

For the desktop review, submit documentation (program descriptions or P&Ps) that contain the performance standards and describe the mechanism for measuring performance and submitting those measurements to the QM committee.  Sample reports, of the sort you submit to the QM committee, should also be submitted for desktop review.

For the onsite review, make sure you have available and clearly marked for the reviewers your QM committee meeting minutes demonstrating that the committee has reviewed those statistics.  Furthermore, staff members and management alike should be familiar with the standards and performance measurement in the event the reviewer asks about them during the interviews.

The Basics

This standard says, essentially, that if the organization has a system by which people are provided financial incentives that are based directly on consumer utilization of healthcare services, there must be mechanisms in place to make sure that these incentives don't end up compromising consumer care.  This policy includes capitation of providers.  Not all URAC reviewers over the years have interpreted this standard this way, so it is helpful to get official clarification on this sometimes controversial issue.

Management Tips

You'll need to assess all your compensation systems at all levels -- staff, management, contractors, and vendors -- to make sure you're thinking broadly enough about this standard.  If you do identify bonuses or incentives that trigger this standard, you'll need to make sure you have one or more methods of making sure that consumers are not underutilizing health services as a result.  Reviewers can be pretty rigorous in examining these methods for assuring your consumers are receiving adequate care, so don't cut corners here.  

URAC Accreditation Tips

This is a mandatory standard.

If you do not have financial incentives, provide either a P&P prohibiting them or a senior executive attestation that you do not and that, if you ever do, you'll first develop mechanisms for assuring that consumer care is not compromised.

If you do have financial incentives related to consumer utilization of health services, make sure you describe them reasonably completely, and then make absolutely sure you document your consumer utilization oversight mechanism.  Once this standard is triggered, the reviewer will be looking closely at how you assure there is no resultant underutilization, so you may as well document it thoroughly up-front.

During the onsite review, the key will be in the interviews.  The people in charge of the utilization oversight mechanism will need to provide reassurance to the reviewer that the methodology is sound, related to the incentives, and likely to detect any problems with consumer utilization.

This is a mandatory standard, so make sure you get it right!

The Basics

The senior clinician whose qualifications are set forth in Pharm Core 31 must, according to this standard, provide guidance and be responsible for all of the clinical aspects of the organization's program being accredited.  In addition, the senior clinician must have periodic consultation with individuals in the field or licensed to deliver healthcare services without supervision, i.e. practitioners.  Finally, he/she must be responsible for your organization's program to assure that all clinicians accountable to your organization for decisions that affect consumers are qualified.

Management Tips

Again come up management personnel should make sure that the senior clinician's job description and resume are in order and in compliance with the standard.  In addition, the organization's program description or policy and procedures that describe the clinician's role in accountabilities should be reviewed to make sure it complies with the standard.

URAC Accreditation Tips

Two of the four elements of the standard are mandatory, the other two are weighted 3.

The same documentation submitted for Pharm Core 10 should be submitted here.  Similarly, the on-site review will turn on the interview of the senior clinician and a review of his/her personnel file.

The Basics

This standard requires that the organization designated at least one senior clinical staff person to perform the functions described in Pharm Core 32.  This standard sets forth at the required qualifications of that person.  Those qualifications are:

• a current unrestricted clinical license,
• sufficient qualifications (e.g., experience, credentials, certifications) to conduct clinical oversight for the services provided by the organization,
• post-graduate patient care experience, and
• if the person is an M.D. or D.O., board certification.

This person typically is the medical or clinical director of your organization.  In a PBM, the general expectation is that he/she is a pharmacist,M.D., or D.O.

Management Tips

People in management positions should keep in mind that it is not sufficient that your senior clinician meet these minimum requirements.  Rather, it is also required that the job description for that person, or some other document describing the person's role, require all of these qualifications.

The person occupying this position can be part time or full time

URAC Accreditation Tips

All of the elements of this standard exit the requirement for board certification are mandatory.  The board certification requirement carries the weight of three.

Documentation for the initial submission should include the designated senior clinician's job description and resume.  In addition, you should submit either a program description or policies and procedures that described the senior clinician's role and accountabilities.

The on-site review will hinge on an interview of the designated senior clinician.  In addition, the reviewer will examine the clinician's personnel file to assure that licensure, board certification, and work history are all documented appropriately.