Quality Management

This particular subsection (formerly Core 33(e)) provides:

The organization has a quality management committee that. . . (e) If applicable, includes at least one participating provider or receives input from a participating provider committee (such as a Physician Advisory Group); (Secondary)

This subsection applies to Health Plans and Health Networks.  The question comes up, "if we don't have a participating provider on the QMC itself, how do we make sure that the input from the participating provider committee is adequate?"

Our answer to this question is, "make sure that anything that is the responsibility of the QMC to receive reports about, or do, or issue reports on, gets to this physician group."  That can be a lot.  As our blog post on QMC responsibilities shows (click here), that may involve a lot of activity.

So, if your physician advisory group is not particularly active, either gear it up to meet the full range of the QMC's clinical responsibilities or play it safe and appoint a participating provider to your QMC.

First-time applicants for URAC accreditation often encounter the challenge of finding or creating a Quality Management Committee (“QMC”) within their organizations. This sometimes is “finding” because a committee by another name may already exist and need only a bit of tweaking to comply with URAC’s requirements for such a committee. In fact, an organization may have two or three committees that are likely candidates for such a designation, and therefore must either elevate one of the committees to that position or create a “super-QMC” to pull together the activities of the other committees. Other organizations will find it advantageous to create a new QMC out of whole cloth.

In this post I will summarize what a QMC should look like and do. I use the term “must” where we found, in either standards or interpretive information accompanying the standards, specific reference to the QMC. I use “should” where we have concluded, based upon our years of experience with URAC-accredited companies’ QMCs, the QMC should be involved to be fully consistent with URAC’s view of QMCs.

Composition

The QMC must have as members:

    * a member of senior management with the authority and responsibility for the overall operation of the quality management program (Core 31(e))
    * at least one participating provider or a mechanism to receive input from participating providers (Core 32(e)), for programs that have participating providers (e.g., Health Plan, Health Network, Pharmacy Benefit Management).

Charter

The QMC must be “granted authority for quality management by the organization’s governing body” (i.e., the Board of Directors) (Core 32(a)).

Meetings

The QMC must meet at least quarterly (Core 33 (c)) and maintain minutes at all its meetings (Core 32 (d)).

Reports the QMC must receive

The QMC must receive, periodically:

    * reports on progress in meeting quality improvement goals (Core 32(h))
    * analyses of consumer complaints and appeals (Core 28)
    * reports on ongoing compliance with URAC standards (Core 33(a))
    * reports on objectives and approaches utilized in the monitoring and evaluation of QM activities (Core 33(b))
    * tracking and trending reports of key indicators relevant to the scope of the entire organization and related to consumer and health care services (Core 33(c))
    * reports on the implementation of action plans to improve or correct identified problems (Core 33(d))

Reports the QMC should receive

The QMC should receive periodic reports on:

    * the results of consumer satisfaction surveys (Core 24)
    * the organization’s performance with respect to its standards to assure that consumers or clients have access to services (Core 25)

Reports the QMC must make

The QMC must provide “on-going reporting to the organization’s governing body.” (Core 31(b))

Specific decisions it must make and actions it must take

The QMC must:

    * approve the quality improvement projects to undertake (Core 32(g))
    * annually evaluate the effectiveness of the QM program (Core 32(i))
    * annually review and update the written description of the organization’s QM program (Core 31(c))

Specific decisions it should make and actions it should take

The QMC should:
    * approve the organization’s mechanism to respond on an urgent basis to situations that pose an immediate threat to the health and safety of consumers (Core 22)

Ongoing activities of the QMC

The QMC must:

    * provide guidance to staff on quality management priorities and projects (Core 32(f));
    * monitor progress in meeting quality improvement goals (Core 32(h))

In its revision of Core 37, URAC has modified the requirements for its "error reduction/consumer safety" project.  There are two changes to note.  First, v. 2.1 adds "for the population served" to subsection (b), so that it now reads:

At any given time, the organization maintains no less than two quality improvement projects . . . (b) At least one quality improvement project focuses on error reduction and/or consumer safety for the population served. 

(Boldface indicates new language)

Presumably, this is to make sure that the applicant's submitted QIP under this subsection provides benefit that is focused on the consumers served by the module under review, and not  the public at large.

The second change that v. 2.1 makes to Core 37 is in subsection (b)(i), and is completely technical, spelling out the names of the accreditation modules that must submit consumer safet QIPs, as opposed to giving their initials ("Health Utilization Management" vs. "HUM").  

Like URAC, I appreciate clarity and am happy to sacrifice brevity on its altar on occasion. 

URAC, in v. 2.1 of Core, has merged two of the standards describing the requirement for quality improvement projects (QIPs), Core 35 and 36. The language of the two standards remains identical, so the only consequences of this change relate to the relative weight of an applicant's score on its QIPs as a percentage of the total Core score. In this sense, the change is similar to the merging of Core 21 and 22, which I described in an earlier blog and will repeat here:

By combining the two standards, URAC reduces the influence of an applicant's quality management program, and particularly its QIPs, at least marginally. The total number of points one can accumulate in the QM world is simply smaller as a percentage of the total number of Core points available in v. 2.1. The requirements of these standards now account for only 16 possible points, not 24, as was the case in v. 2.0.

However, the consequence of any mistake within this standard is increased by the change in weight from 3 to 4. Previously, any missed primary element (and most of the elements are primary) cost an applicant 9 points. In v. 2.1, with the higher weighting value, a mistake in a primary element has a price of 12 points.

As is often the case, a review of my blog on URAC scoring may be helpful at this point.

First-time applicants for URAC accreditation often encounter the challenge of finding or creating a Quality Management Committee (“QMC”) within their organizations. This sometimes is “finding” because a committee by another name may already exist and need only a bit of tweaking to comply with URAC’s requirements for such a committee. In fact, an organization may have two or three committees that are likely candidates for such a designation, and therefore must either elevate one of the committees to that position or create a “super-QMC” to pull together the activities of the other committees. Other organizations will find it advantageous to create a new QMC out of whole cloth.

This is particularly true in the world of pharmacy benefit managers (“PBMs”). Most PBMs of which we at Integral Healthcare Solutions are aware will have to do a bit of fiddling with their committee structures to meet the various URAC standards that address the structure, role, and responsibilities of the QMC. It is timely then, as URAC reviewers criss-cross the nation conducting the onsite reviews of the 10 PBMs participating in URAC’s “beta” program for its nascent PBM standards, to summarize what a PBM QMC should look like and do. I use “must” where we found, in either standards or interpretive information accompanying the standards, specific reference to the QMC. I use “should” where we have concluded, based upon our years of experience with URAC-accredited companies’ QMCs, the QMC should be involved to be fully consistent with URAC’s view of QMCs.

Composition

The QMC must have as members:

• a member of senior management with the authority and responsibility for the overall operation of the quality management program (Core 32(e))
• at least one participating provider or a mechanism to receive input from participating providers (Core 33(e)).

Charter

The QMC must be “granted authority for quality management by the organization’s governing body” (i.e., the Board of Directors) (Core 33(a)).

Meetings

The QMC must meet at least quarterly (Core 33 (c)) and maintain minutes at all its meetings (Core 33 (d)).

Reports the QMC must receive

The QMC must receive, periodically:

• reports on progress in meeting quality improvement goals (Core 33(h))
• analyses of consumer complaints and appeals (Core 29)
• reports on ongoing compliance with URAC standards (Core 34(a))
• reports on objectives and approaches utilized in the monitoring and evaluation of QM activities (Core 34(b))
• tracking and trending reports of key indicators relevant to the scope of the entire organization and related to consumer and health care services (Core 34(c))
• reports on the implementation of action plans to improve or correct identified problems (Core 34 (d))

Reports the QMC should receive

The QMC should receive periodic reports on:

• the results of consumer satisfaction surveys (Core 25)
• the organization’s performance with respect to its standards to assure that consumers or clients have access to services (Core 26)
• ongoing compliance with operating requirements for the call center for in-bound telephone calls (CSCD 7)

Reports the QMC must make

The QMC must provide “on-going reporting to the organization’s governing body.” (Core 32(b))

Specific decisions it must make and actions it must take

The QMC must:

• approve the quality improvement projects to undertake (Core 33(g))
• annually evaluate the effectiveness of the QM program (Core 33(i))
• annually review and update the written description of the organization’s QM program (Core 32 (c))

Specific decisions it should make and actions it should take

The QMC should:

• approve the organization’s mechanism to respond on an urgent basis to situations that pose an immediate threat to the health and safety of consumers (Core 23)
• review and approve the organization’s systems:
  • for identifying and communicating drug-drug interactions at point-of-service (DrUM 5(a)); and
  • of drug utilization management tools, such as prospective and concurrent DrUM that identifies situations which may compromise the safety of the consumer (DrUM 5(b))

Ongoing activities of the QMC

The QMC must:

• provide guidance to staff on quality management priorities and projects (Core 33(f));
• monitor progress in meeting quality improvement goals (Core 33(h))

One of the areas in which the new emphasis on error reduction and consumer safety is Core 37:

Core 37 – Clinical, Error Reduction, and Consumer Safety Requirements
At any given time, the organization maintains no less than two quality improvement
projects.
(a) At least one quality improvement project that:
(i) Focuses on consumers; or for organizations who do not interact with
consumers, client services;
(ii) Relates to key indicators of quality as described in 34(c); and
(iii) Involves a senior clinical staff person in judgments about clinical aspects of
performance, if the quality improvement project is clinical in nature; and
(b) At least one quality improvement project focuses on error reduction and/or
consumer safety.
(i) Consumer safety QIPs are required of the following programs: HUM, WCUM,
HCC, HP, DM, IRO, and CM.
(ii) Error reduction QIPs are required of all accreditation programs that do not
conduct consumer safety QIPs.

There are a few key things to keep in mind about this standard and the quality improvement programs (QIPs) it mandates:

• URAC reviewers will interview the senior clinical staff person to assess his/her involvement in clinical judgments (subsection (a)(iii)).
• The requirement for patient safety applies only to certain modules (HUM, WCUM, HCC, HP, DM, IRO, and CM). All the rest of the clinical programs can use an error reduction QIP.
• A good place to look for ideas for QIPs are barriers to proper medical management, use of current triage guidelines, integration of quality information, patient access issues, sentinel events tracking, etc.
• Make sure the baseline and goals are measurable, and in the same units.
• Make sure your goal is connected to a target date for achievement.

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.