Personnel

URAC has long required organizations to demonstrate that they train their employees and senior clinical staff members in a variety of areas, including confidentiality, conflict of interest, and the applicable URAC standards.  The current (v. 3.0) Core 27 reads:

The organization has an ongoing training program that includes: (No Weight)
    (a) Initial orientation and/or training for all staff before assuming assigned roles and responsibilities; (2)
    (b) Training in current URAC standards as appropriate to job functions; (2)
    (c) Conflict of interest; (4)
    (d) Confidentiality; (Mandatory)
    (e) Documentation of all training provided for staff; and (2)
    (f) Ongoing training, at a minimum annually, to maintain professional competency. (2)

The question here is "what do I submit on AccreditNet for Desktop Review?"  The Interpretive Information suggests:

• Training program outlines/agendas for all levels of program staff (employee and senior clinical staff person) that include all elements of the standard.
  

• Tools used to document orientation and training activities.

The first bullet is similar to the earlier versions of Core, while the second bullet is new.  What is also new is that URAC reviewers are more rigorously enforcing this documentation requirement.  There was a time when it would have been sufficient for most URAC reviewers to submit, at the Desktop Review phase, a P&P outlining training requirements and a couple of examples of agendas and sign-in sheets of various trainings. 

In recent weeks, however, we've seen evidence that URAC reviewers are taking this submission requirement more literally than in previous years.  So, we recommend that you do exactly as suggested -- submit for Desktop Review a full complement of training program outlines and agendas for all employees across all the required types of training.  

I talk a bit more about this in the following 3-minute video.

A new interpretation of an old standard came to our attention today.  Core 10(d) requires:

The organization designates at least one senior clinical staff person who has: (Primary)
    * * *
    (d) Board certification (if the senior clinical staff person is an M.D. or D.O.). (Secondary)

Historically, it has been sufficient to submit evidence of board certification.  At least one URAC reviewer now requires additional documentation, i.e., that the job description for this person require board certification.

For a 7-minute video on URAC training, click here.

In any event, read on:

It is useful to think about the issue of "training" in two compartments -- (1) training required by URAC and (2) training for the onsite review.  I will handle them separately.

1.  Training required by URAC

As you know, URAC has specific requirements for staff training that relate both to the content of staff training and its administration:

Content
Most of the explicit training requirements in the URAC standards are found in the Core and Pharm Core standards: 

• Initial orientation and/or training for all staff before assuming assigned roles and responsibilities; (Core 7(a))
  • Training in the P&Ps that apply to one's job is implied by Core 3(a), too
• Ongoing training, at a minimum annually, to maintain professional competency; (Core 7(b))
• Training in current URAC Standards as appropriate to job functions; (Core 7(c))
• Training in state and regulatory requirements as related to job functions; (Core 7(d))
• Conflict of interest; (Core 7(e))
• Confidentiality (Core 7(f)) and specifically HIPAA (Core 24)
• Training on identification and prevention of fraud and abuse, as appropriate to job functions; (Core 7(g))
• Delegation oversight, if necessary; and (Core 7(h))

In addition, training of employees in how to do their job consistent with company P&Ps and URAC standards  is implied throughout the standards, via Core 3(a), 7(a), and 7(c).

Administration

• There must be documentation of all training provided for staff (Core 7(i))
• There must be a signed document acknowledging training on confidentiality issues (Core 24)

Some of this is company-wide training (e.g., confidentiality); some is department-specific (e.g., P&Ps on how to follow DM P&Ps.)  Company-wide training is typically handled either through:

1. company-wide meetings
2. computer-based training modules required of all employees, or
3. smaller, face-to-face trainings required of all employees. 

Department-specific training is typically handled through

1. modular computer-based training programs or
2. departmental staff meetings

2.  Training for the URAC Review Process

The best preparation for the URAC review is the substantive training described in the previous section.  A staff member who knows his/her job as described by the applicable P&Ps, knows the URAC standards and state/federal regulations that apply to the job, and can retrieve the documents to be sought by the URAC reviewer is unlikely to get tripped up in a URAC review, even if they have no specific preparation for the onsite review process.

Additionally, the mock onsite review we conduct for our clients is valuable for staff members likely to be either interviewed or pulling documents during the onsite review.  We spend a good portion of our time onsite not only conducting document-pulls and interviews as realistically as possible, but also counseling staff members on how to improve their performance for the actual review.

This standard may be the shortest ever:

Staff meets qualifications as outlined in written job descriptions. (Primary)

It carries a weight of 3, and, like Core 4, has a straightforward documentation requirement at the AccreditNet phase of the process: submit job descriptions.  You may (and should) submit the same documents you submitted for Core 4.

The difference here with Core 4 is in the onsite review: for the staff members selected from the employee directory, the reviewer will compare the job descriptions' requirements to the résumés of the respective employees to make sure that they meet the requirements as outlined in the job descriptions.  The personnel file audit we recommend in our lengthier blog on the topic (click here) should include a check for that concurrence between job descriptions and résumés.

The proposed changes to Core 9, which deals with the staff assessment program, could not be more insignificant.  There are no substantive changes, and the only scoring change elevates, ever so slightly, the significance of the "review of relevant documentation produced by that individual staff member" over the annual performance appraisal, which, in the current version, are of equal weight. 

I'm guessing few people will be submitting searing comments on this proposed change.

The new standard would read:

The organization maintains a formal assessment program for individual staff members that includes: (---)
(a) An annual performance appraisal; and (Wt = 2)
(b) A review of relevant documentation produced by that individual staff member. (Wt = 3)

This standard, which focuses on staff operational tools and support, changes in only one substantive way -- URAC proposes to move a training requirement for state and federal regulations from Core 7 to this standard.  The new standard would read:

The organization provides staff with: (--)
(a) Written operational policies and procedures appropriate to their jobs; (Wt = 2)
(b) Clinical decision support tools as appropriate; and (Wt = 3)
(c) Regulatory requirements as related to their job function. (W = 3)

If there is a difference between requiring training in regulatory requirements and providing staff with regulatory requirements, I cannot detect it.  Similarly, the scoring changes are not particularly dramatic.

URAC is proposing to do some housekeeping with Core 7, the primary staff training standard.  The proposed revision moves required regulatory training to Core 8, and the requirement for fraud and abuse training to Core 19.  The proposed new version would read as follows:

The organization has an ongoing training program that includes:
(--)
(a) Initial orientation and/or training for all staff before assuming
assigned roles and responsibilities; (Wt = 2)
(b) Ongoing training, at a minimum annually, to maintain
professional competency; (Wt = 2)
(c) Training in current URAC Standards as appropriate to job
functions; (Wt = 2)
(d) Conflict of interest; (Wt = M)
(e) Confidentiality; (Wt = M)
(f) Delegation oversight, if necessary; and (Wt = 3)
(g) Documentation of all training provided for staff. (Wt = 2)

The most significant change that URAC is proposing relates to scoring.  While the requirement for confidentiality and conflict of interest training are primary elements in the current standard, the current standard is not mandatory.  By changing confidentiality and conflict of interest training requirements to mandatory elements, URAC is proposing to elevate their importance by putting the accreditation of an applicant failing in either of these two domains at risk.

Alert the training department! 

Case Management standard 7, dealing with Case Management Knowledge Domains, gets a good housecleaning in the v. 3.1 revision.  The only substantive change is the elimination of a requirement that case managers be trained in URAC's current Case Management standards.  Since Core 7 requires URAC training on the applicable standards in any event, this was an unnecessary clause.  The rest of it is simply the breaking up into 4 separate subsections what was once a single subsection, allowing the reviewer more precise scoring.

The v. 3.0 version read:

The organization requires case managers to be educated in current principles, procedures, and knowledge domains of case management based on nationally recognized standards of case management. Such education includes: (Prim)
(a) The organization’s case management process, policies and procedures; state-specific requirements; professional roles and resources; and requirements specific to the clinical or payer populations being served; (Primary)
(b) URAC’s current Case Management Standards; and (Secondary)
(c) Relevant professional education on at least an annual basis. (Secondary)

The v. 3.1 version now reads:

The organization requires case managers to be educated in current principles, procedures, and knowledge domains of case management based on nationally recognized standards of case management. Such education includes: (Primary)
(a) The organization’s case management process, policies and procedures; (Primary)
(b) Applicable regulatory requirements; (Prim)
(c) Professional roles and resources; (Primary)
(d) Requirements specific to the clinical or payer populations being served; and (Primary)
(e) Relevant professional education on at least an annual basis. (Secondary)

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
• URAC and 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:

1. 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.
2. 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.
3. 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.
4. 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.