URAC Core

As is the case with the other three delegation standards (Core 15-17), URAC proposes no substantive changes to Core 18, Delegation Oversight.  The new standard would read:

The organization establishes and implements an oversight mechanism for delegated functions within the scope of accreditation that includes: (--)
(a) A periodic review (no less than annually) of the contractor’s policies and procedures and documentation of quality activities for related delegated functions; (Wt = 3)
(b) A process to verify (no less than annually) the contractor’s compliance with contractual requirements and policies and procedures; and (Wt = 3)
(c) A mechanism to monitor financial incentives to ensure that quality of care or service is not compromised. (Wt = M)

What is significant about the scoring change is that (c) becomes a mandatory standard.  URAC has attached the "M" designation to a host of new elements that deal with consumer protection, and this is an example of that.  The import of this change is that those staff members charged with delegation oversight now will need to pay particular attention to documenting the method by which they assure that those contractors that have financial incentives in their compensation structures do not compromise quality of care. 

URAC apparently believes (with good reason, in my view), that its current delegation standards are fine just as they are, and therefore proposes no changes in the heart of the four delegation standards, Core 17. This standard outlines the required elements of the contract of delegation between the accredited organization and the contractor:

The organization enters into written agreements with contractors that: (--)
(a) Specify those responsibilities delegated to the contractor and those retained by the organization; (Wt = 2)
(b) Require that services be performed in accordance with the organization's requirements and URAC standards; (Wt = M)
(c) Require notification to the organization of any material change in the contractor’s performance of delegated functions; (Wt = 4)
(d) Specify that the organization may conduct surveys of the contractor, as needed; (Wt = 2)
(e) Require that the contractor submit periodic reports to the organization regarding the performance of its delegated responsibilities; (Wt = 3)
(f) Specify recourse and/or sanctions if the contractor does not make corrections to identified problems within a specified period; (Wt = 2)
(g) Specify the circumstances under which activities may be further delegated by the contractor, including any requirements for obtaining permission from the organization before any further delegation; and (Wt = 4)
(h) Specify that, if the contractor further delegates organizational functions, those functions shall be subject to the terms of the written agreement between the contractor and the organization and in accordance with URAC standards. (Wt = M)

Substantively, the only changes brought about by the scoring system change (other than the fact that the multitude of elements to this standard inevitably gives it morerelative importance than it has in the current system) have to do with which elements are now mandatory. In this regard, there was a major reshuffling of priorities. In the current version the current mandatory elements (I consider any "primary" element in a standard weighted "5" mandatory) are subsections (a), (b), (c), (f), and (g). The proposed revision would make only subsections (b) and (h) mandatory. The transformation of (h) into a mandatory standard should be noted by the contracting department, as this is a frequently missed elements not only by first-time applicants, but by some reaccreditation veterans, as well.

Finally, URAC proposes to help applicants with the following addition to the Interpretive Information:

Examples of “material change” in Core 17(c) for the delegated entity include a change of address, loss or replacement of the senior clinical staff person, and prolonged interruption of services due to any cause (e.g., natural disaster, IT systems down, decrease in staffing, substantive change in delegated processes, etc.)

This is useful, in our view, as a number of our clients have expressed puzzlement about what this clause was intended to address.     

The only changes URAC proposes for Core 16, which describes the required process for reviewing proposed contractors, is in scoring, and even those changes are minor:

Prior to delegating functions to another entity, the organization: (---)
(a) Establishes and implements a process to conduct a review of the potential contractor’s policies and procedures and capacity to perform delegated functions; and (Wt = 3)
(b) Outlines and follows criteria and processes for approving contractors. (Wt = 3)

URAC-accredited companies will need to add a client satisfaction assessment mechanism under a proposed new standard.  The new standard would read:

The organization implements a mechanism to collect or obtain information about client satisfaction with services provided by the organization. (Wt = 3).

Oddly, the explanatory note to the revision claims that Core 24 currently applies to client and consumer satisfaction assessment, and that this new standard simply splits the client piece of that off into its own standard.  That simply is not true.  Core 24 applies exclusively to consumer satisfaction, as is evidenced by this explanatory note in the current version of Core: "Core 24 refers to consumer satisfaction information regarding the program. This standard may not be applicable to programs that do not interact with consumers."

So, rather than a mere reorganization, this is a distinctly new requirement, never before required of URAC applicants.  This is not to say I think it's a bad idea -- we at Integral Healthcare Solutions conduct client satisfaction surveys regularly.  I only comment on this to make it crystal clear that this is a new requirement, not a repackaging of an old one.

The scoring for the new standard is a barely significant "3", which, under the new scoring system, is barely noticeable.   

URAC-accredited companies will have to notify clients of material misrepresentations under a new standard proposed by URAC.  But first, some background:

URAC applicants that have relationships with both clients and consumers long have been confused by Core 21, which addresses communications practices for both.  (Remember, a "client" is the "business or individual that purchases services from the Organization," while a "consumer" is the "individual person who is the direct or indirect recipient of the services of the Organization.")   URAC is clearing up that confusion by limiting Core 21's applicability to consumers and creating a new standard for communications with clients.  That new standard would read:

The organization follows marketing and communication practices with clients that include: (--)
(a) Mechanisms to clearly and accurately communicate information about services inclusive of delegated activities to clients; (Wt = 3)
(b) A formal process of inter-departmental review of marketing materials before dissemination to clients to safeguard against misrepresentations about the organization’s services; and (Wt = 3)
(c) Monitoring of existing materials for accuracy; and (Wt = 3)
(d) Timely and complete correction notices to clients if any material misrepresentations are found. (Wt = M)

Subsections (a) and (c) are fundamentally unchanged from their Core 21 equivalents.  Subsection (b) is little more than the collapsing of two subsections of Core 21 ((b) and (c)) into one element.  The only substantively new element is (d), which, notably, is the only mandatory element of the new standard.  Most current URAC-accredited companies will need to add this provision to their communications policies, requiring "timely and complete correction notices" in the event of material misrepresentations.   

The proposed change in Core 14 is barely perceptible, even to the trained eye.  The new standard would read:

Core 14 – Written Business Agreements
The organization maintains signed written agreements with all clients describing the scope of the business arrangement. (Wt=2)

The scoring weight's the same, the language is the same --  then what is it?

Ah, there it is!  The title would change.  The current standard is called "Business Relationships."  This simply makes the title of the standard more closely depict the content of the standard -- a requirement that applicants have contracts with their clients.  

Big changes are afoot regarding Core 13, the Information Management Standard.  In the proposed revision, URAC adds some much-needed heft to the standards and separates it into three distinct standards.  So, components that are now in Core 13 (confidentiality, security, and disaster recovery) will be split off from Core 13 into two new standards.  What will be left is the following:

The organization implements information system(s) (electronic and paper) to collect, maintain, and analyze information necessary for organizational management that: (No wt stem)
(a) Provides for data integrity; (Wt = M)
(b) Includes a plan for storage, maintenance and destruction. (Wt = 2)
(c) Includes a plan for interoperability: (Wt = L)
  (i) Between internal information systems; (--)
  (ii) With external entity information systems. (--)

There's much to talk about here.  First, URAC proposes to make clearer what has long been true but widely misunderstood (see my blog from 12/5/07), that this standard applies to electronic and paper information systems.  By moving this explanation from the interpretive information to the standard itself, URAC is signaling that it really wants to get the attention of applicants:  paper counts, too!   And, it counts not only for storage, maintenance and destruction, but also for data integrity.

What do you mean by data integrity?  Another old issue for URAC applicants, as you can see in my blog from 8/6/06.  Currently, URAC defines this term in the interpretive information accompanying Core 13, but in the revision, URAC proposes to make it a defined term:

The quality or condition of being accurate, complete and valid, and not altered or destroyed in an unauthorized manner.

URAC then takes the relatively unusual step of citing its source: www.ecommercepki.com/cps/glossary.htm. 

This is a modest change from URAC's current view of "accuracy and traceability."

The other big change here is the addition of a new section on interoperability.  URAC would define the term as meaning:

Ability of two or more systems or components to exchange information and to use the information that has been exchanged.

This is the first of the proposed revisions to carry the new scoring designation of "L".  An "L" standard is a "Leading Indicator," a "non-weighted, optional element highlighting effective practices not yet widely adopted in health care."  You lose no points for missing such a standard, but, under certain circumstances, you may be able to use your compliance with the standard to distinguish yourself from other URAC-accredited companies.  Click here to see the full URAC explanation of this at my blog on the topic. 

At the 2008 Summit, URAC staff members explained that the applicant will get credit for this standard with merely an approved plan, regardless of the stage of implementation of that plan.

This element is driven by the "Four Cornerstones" for health care improvement of the US Department of Health and Human Services.

One of the new changes in URAC's new scoring system is the "Leading Indicator".   Here's what URAC says about it:

Leading Indicator: Non-weighted, optional element highlighting effective practices not yet widely adopted in health care

• Potential forecast of where the health care industry may be heading
• Provides a way for an organization to distinguish itself from other accredited companies
• Leading indicators is not reported to URAC’s Accreditation or Executive Committees and do not influence an applicant’s final accreditation score or category
• Cannot be designated “not applicable” given that they are optional
• Before URAC will acknowledge that an applicant has met a leading indicator:
•     Full accreditation must be achieved, and
•     Element must be met at 100% compliance
•     Initially URAC will list leading indicators in the Accreditation Summary Report (ASR)
•            Other types of marketing exposure may be considered in the future (e.g., Web site, conferences, etc.)

URAC is not clear about this future marketing exposure, but given the just-concluded awards conference, you can bet that this will be a consideration in future awards. 

URAC proposes to add a new standard in v. 2.1:

The organization establishes and implements mechanisms to promote collaboration and communication with applicable external entities to coordinate health services for consumers. (Wt = 1)

This obviously is a trial balloon, because the assigned weight of this single-element standard is "1".  The explanation offered by URAC:

Lack of coordination among health care organizations results in unsafe, inefficient care. Key stakeholders, including employer groups and patient advocates, want providers in the industry to conscientiously coordinate care.

URAC goes on to explain its intent:

In the interest of safe, quality health care, organizations must establish processes to promote cooperation and effective communication with other organizations.

This standard will apply only to the coordination of clinical services to consumers. 

URAC is proposing no notable changes for Core 12, its "anti-silo" standard that encourages interdepartmental coordination.  The only change is the across-the-board scoring change:

The organization establishes and implements mechanisms to promote collaboration, coordination, and communication across disciplines and departments within the organization, with emphasis on integrating administrative activities, quality improvement, and where present, clinical operations. (Wt = 3)

As I explain elsewhere, as a single-element standard, the scoring change significantly decreases the relative importance of this standard, vis-a-vis multi-element standards.