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This standard has two mandatory subsections and a third subsection that is a "leading indicator":

The wellness organization selects and designs defined interventions that are: (---)
(a) Consistent with and supported by evidence-based practices; (M)
(b) Approved by a committee designated by the wellness organization to have authority over the clinical aspects of the wellness program; and (M)
(c) Within three years of initial accreditation, provides level of evidence supporting interventions to health benefits purchasers proactively and to consumers upon request. (L)

Subsection (a) echoes from earlier standards URAC's insistence on basing the fundamental components of a wellness program on evidence.  So, like the health risk assessment tool, the interventions must be evidence-based. Affirmative documentation demonstrating that the intervention was based on current clinical research will be an essential part of the submission to AccreditNet.  Additionally, however, URAC is almost sure to require that the program have a policy and procedure that requires the basing of the design of interventions on clinical evidence. 

Subsection (b) is written in a curious way, particularly when read together with the Interpretive Information.  The standard is unambiguous in requiring that the interventions be approved by a committee.  The interpretive guide, however, suggests that this could be something other than a standing committee, that is, the senior clinical officer could approve it in consultation with other providers, not necessarily a standing committee.   While I find it curious that the standard itself doesn't say that a committee is not required; on the contrary, it explicitly requires committee review.  That being said, applicants can take URAC at its word, at least for the initial version of the standard, and, if they choose, may submit evidence of approval by the senior clinical officer.  However, those that take the individual approval route rather than the committee approval route almost surely will require evidence that the senior clinician, in fact, did consult with others in the design and selection of interventions.  Absent such evidence, the applicant runs the risk of violating this mandatory subsection.

The leading indicator subsection (c) places a responsibility on the organization to provide the evidence it used in designing the intervention to the employer -- without the requirement of a request by the employer for that evidence.  Additionally, the program will have to provide such evidence to participants upon request.  Again, not only will there need to be documentation that this evidence was provided, but that the program has a policy and procedure requiring that it submit such documentation to employers and participants in a manner that complies with this subsection.

The onsite review for this standard is likely to be a combination of interviews with relevant personnel and documentation to be submitted onsite upon selection of employers from a list of employers.  Furthermore, the applicant would do well to maintain a log of participant requests for such evidence, from which the reviewer will select files to determine how responsive to those requests the program has been.

Subsec

This is a mandatory standard, which provides:

The wellness organization has adopted evidence-based behavioral change model(s) that promote healthy behavior for all participants.

There are, of course, a wide array of widely recognized decision-making and behavioral change models.  As a side note, I did my doctoral dissertation on one model mentioned by URAC in the "Interpretive Information" section, the Theory of Planned Behavior.  Certainly, if the program uses such a widely recognized model, the documentation required to demonstrate compliance with this standard is modest -- a clear articulation of the model and brief description of its elements will probably be sufficient.  However, if the behavioral change model is not widely recognized, URAC will allow an alternative model, but you can bet the documentation requirements will be steeper.  A safe bet is that an articulation of the research underlying the operating model will be required by the reviewer if it is a less-well-known model.

Onsite, the reviewer is likely to cover this standard primarily in the interview, in an effort to make sure that the designers of the interventions are familiar with the behavioral change model being applied and how it relates to the interventions in the Program.

This mandatory standard provides:

At least every two years, the wellness organization reviews and, if necessary, modifies the health risk assessment tool based on clinical updates and other research.

The underlying assumption of this standard is that, since the program's structure, including risk assessment and stratification methodologies, is evidence-based, that evidence conceivably could change over time, as new clinical research becomes available.  Therefore, URAC requires that the program remain current with that research by reviewing current literature and modifying the program to reflect current research. 

Documentation required for this standard likely will include evidence of review, by qualified people, of current research on the topic and the comparison of recent research to the health risk assessment tool currently used by the organization.  Onsite review may include an interview with the person or persons who conducted that review and, perhaps, committee meeting minutes if the review results are presented to a committee.

This mandatory standard provides:

The wellness organization applies the health risk assessment process on a specified and periodic basis.

This does not mean that the initial assessment needs to be repeated in full.  Indeed, URAC is clear that a pared-down version will be perfectly fine, so long as the program is monitoring risk factors with enough specificity to modify interventions for the participant where appropriate.

The application documentation should provide either a clear policy and procedure with specified intervals for reassessment or a clearly articulated method for collaborating with each employer on a regular and frequent reassessment.

The onsite review no doubt will include, in addition to the interview of relevant personnel, documentation of the periodicity of risk assessments across a sample, selected by the reviewer, of employers.

This 3-weighted standard reads:

The wellness organization has a process to apply inclusion criteria, based on the health risk assessment process, for the wellness program.

Because a Wellness Program is not likely to be asked by the employer to include the entire population of employees, this standard contemplates a selection of a subset of that population for participation.  The selection method, under this standard, needs to be a clearly-articulated approach, replete with "inclusion criteria" based on the health risk assessment method used in the Program.  "Inclusion criteria" is defined by URAC as "The factors, typically defined by the purchaser, that determine whether an individual is within the target population of the wellness program."

Whenever URAC uses the word "process", you can bet the documentation required will be a formal policy and procedure or other description of the Wellness Program.  Onsite evaluation is likely to be a combination of documentary review of the application of the criteria to select participants, as well as an interview with the staff members charged with applying the criteria to the data for participant selection.

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))

This mandatory standard provides:

The wellness organization has a process to conduct an individualized assessment of each program participant. (M)

Thus, at the heart of the URAC accreditation is the ability of the organization to conduct individualized assessments of program participants.  In other words, the organization cannot merely focus its data collection at the population level, but must be able to provide information that is useful to the individual.  

A program description, combined with examples of individualized assessment reports, are likely to satisfy the documentation requirements for the purposes of the desktop review.  Onsite review activities regarding this standard are likely to be a combination of interviews with senior management and an examination of assessment reports of randomly selected participant assessment reports, drawn from a list of all program participants.

This standard speaks to the data analytic capacity of the organization:

The wellness organization has the ability to use additional and credible data sources in conjunction with the health risk assessment tool data to help stratify the target population. (4)

Thus, in this standard, URAC hopes to insure that URAC-accredited wellness programs be able to respond to a purchaser's request to include information in addition to screening results in its stratification of the target population.  

One can anticipate that the documentation required to demonstrate compliance with this standard will include a program description and two or three examples of the use of such information in population stratification.  The onsite review is likely to focus on an interview with those in the wellness organization who are most familiar with the data analytic capacity of the organization.

This standard provides:

The wellness program: (---)
(a) Provides access to periodic screenings for health problems and referrals for appropriate follow-up measures and (L)
(b) Discloses to the participant the purpose(s) and use of the screening data. (4)

A blend of a leading indicator subsection and a 4-weighted subsection, this standard carves out two types of consumer rights -- one for access to screenings and one to transparency as to the purpose and use of the screening data. At least in the first version of the standards, URAC proposes to require only the latter.

The purposes of such screenings include raising awareness, recruiting participants into wellness programs, and helping both the participant and the wellness organization during interventions.

What, precisely, would be addressed in such health screenings is best clarified by this interpretive comment:

Health screenings may include, but are not limited to, basic biometric data collection, such as blood pressure, heart rate, weight, and height. Additional risk factor measures are also acceptable (e.g. cholesterol; family and medical history).