The Basics

This standard sets forth the requirements for the quality improvement projects your organization will submit to URAC.  Under these standards, your quality improvement projects must:

• have clearly-defined quantifiable measures
• measure your organization's baseline performance
• re-measure performance at least annually as compared to the baseline performance
• create specific goals for performance that are an improvement over the baseline performance
• establish strategies for performance improvement
• articulate projected time frames for the achievement of performance improvement goals
• conduct a barrier analysis if the organization does not achieve its performance goals

Management Tips

URAC provides a form that you may use to document your quality improvement projects, known as the Quality Improvement Project Description Form.  While use of this form is not required for accreditation, we strongly recommend that you use it, as it will help you assess whether a particular quality improvement project is a good candidate for submission to URAC.  In addition, URAC reviewers have a strong preference for the official form, as it allows them to see all of the essential elements of your quality improvement project in a format they can understand easily.  If your project is a HEDIS study, it will qualify under this standard.

In order for the quality improvement projects to qualify under this standard, it must be underway (interventions have begun) and leased by the time of the on-site review.  If the project was completed before the review, it can be no older than one year old by the time of the on-site review.

URAC Accreditation Tips

All of the elements of these three standards carry a weight of three.

For the desktop review, all you need to submit are the quality improvement Project description forms for each of the submitted projects.

For the on-site review, prepare a PowerPoint presentation in which you can easily show not only the structure and operation of your quality program, but each of the submitted quality projects.  This presentation is typically given immediately after the opening presentation of the on-site review.  In addition, the reviewer will examine quality improvement committee meeting minutes for evidence that the committee has signed off on these projects.  Keep the presentation simple, and focus on presenting the results of your most recent measurements and on the most recent interventions.

The Basics

The standard requires your organization to maintain, at all times, at least two quality improvement projects relating to error reduction or performance improvement.  If your organization is seeking accreditation in more than one accreditation program, each accreditation program will have to have two QIPs.  However, it is at least conceivable that a QIP could perform double- or triple-duty, depending on its design.

The quality improvement projects need not be organization-wide; they can focus on a program or function covered by the accreditation program.

Management Tips

Your quality management program description and, if you have one, your quality management plan should address your quality improvement projects.  Those documents should establish standards for how to design your projects, consistent with the standard and the ones that follow.  In addition, we recommend that you track your quality improvement projects on the standardized form, either the one provided by URAC or another industry standard form.  These are not only useful forms for your accreditation review, but provide a consistent means of reporting to the relevant committees.

URAC Accreditation Tips

This is a mandatory standard.

For purposes of the desktop review, submit both your quality policies and procedures that discuss quality improvement projects and two completed quality improvement project description forms.

During the on-site review, you will be expected to give a PowerPoint presentation discussing not only a quality management program, but specifically the quality improvement projects you submitted.  The presentation will provide the reviewer with an opportunity to follow-up with any questions he or she may have about the projects.

The Basics

This standard both requires that the organization establish a quality management committee and establishes the minimum requirements for the operation of that committee.

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 
• at least one participating provider or a mechanism to receive input from participating providers, 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) .

Meetings

The QMC must meet at least quarterly and maintain minutes at all its meetings.

Reports the QMC must receive

The QMC must receive, periodically:

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

Reports the QMC should receive

The QMC should receive periodic reports on:

• the results of consumer satisfaction surveys
• the organization’s performance with respect to its standards to assure that consumers or clients have access to services

Reports the QMC must make

The QMC must provide “on-going reporting to the organization’s governing body.” 

Specific decisions it must make and actions it must take

The QMC must:

• approve the quality improvement projects to undertake
• annually evaluate the effectiveness of the QM program
• annually review and update the written description of the organization’s QM program 

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 

Ongoing activities of the QMC

The QMC must:

• provide guidance to staff on quality management priorities and projects;
• monitor progress in meeting quality improvement goals

Management Tips

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.

URAC Accreditation Tips

This elements of this standard has a weight of either 2 or 3.

As is true for nearly all of the quality management standards, the basic document to submit to support the standard is the quality management program description.  In addition, for the standard, you should submit either a formal quality management program evaluation or minutes from a meeting of the quality management committee in which the committee evaluated the program's effectiveness.

To prepare for the on-site review, make sure that you flag the portions of the quality management committee minutes that specifically support each element of this standard.

The Basics

This standard requires that your organization's quality management program have sufficient staff and other resources to function properly.  While this does not necessarily mean your organization has a distinct department solely dedicated to quality management, it does require that at least some portion of some employees' time be dedicated to quality management, and the fact be clearly delineated in both the quality management program description and job descriptions of the involved personnel.

URAC Accreditation Tips

This standard has a weight of 3.

For the desktop review, submit the quality management program description and the job descriptions of staff members involved in quality management.

Again, during the onsite review, the reviewer will focus on examining quality management committee minutes and interviewing staff members involved in quality management.

The Basics

This standard sets forth the general requirement that your organization must have a quality management program.  It requires that the program promote systematic measurement and evaluation of services provided by the organization.  It also requires that, when the organization, through this performance monitoring, encounters opportunities for improvement, the organization implements quality improvement activities.

This is a very general requirement, the details of which are spelled out in the succeeding standards.

Management Tips

Probably the best way to address this standard and those that follow is to write a comprehensive quality management program description that does not change significantly from one year to the next.  In addition, a quality management plan that is updated annually will be an excellent document in which to set short term goals for quality management program.  the former of these two documents can be a compilation of all the policies and procedures of that relate to quality management, or, instead, a concert in place of the policies and procedures.

URAC Accreditation Tips

This standard is mandatory.

For the desktop review, submit the quality management plan (with a quality management policies and procedures), as well as the job descriptions for key quality management department personnel, deeply those in management positions.

For the on-site review, you can expect the URAC reviewer to examine minutes of the meetings of your quality management committee for the last two or three years.  In addition, the reviewer will conduct an interview of senior staff members involved in the quality management program, usually in the first morning of the on-site review.  Quality management staff member should be prepared to present a PowerPoint presentation during that interview.

The MAO must have an ongoing quality improvement (QI) program that is formally evaluated at least annually.

The Basics

The standard outlines the minimum requirements for your quality management program.  URAC makes it quite clear that each one of these elements must be clearly documented:

• goals and methods used in monitoring and evaluating quality management activity;
• the identification, tracking, and trending a performance measures (including access to services, complaints, and satisfaction);
• the use of quantifiable measures to establish acceptable levels of performance;
• measurement of baseline levels of performance;
• annual re-measurement of performance;
• action plans to correct or improve performance where needed to meet performance goals;
• methods to communicate these quality activities to the relevant members of the staff;
• reporting of such activities to the quality management committee.

Management Tips

This is a new standard in which URAC takes nearly all of the components of its quality improvement project requirements and extends them to your performance measures.  Therefore, even if you haven't identified a performance measure as an area suitable for quality improvement project, you still should be measuring a performance against clear goals on a periodic basis and making corrections when you don't meet those goals.

The essential part of the standard for managers is making sure that you have a policy and procedure that clearly outlines how all of these elements are to be documented.

URAC Accreditation Tips

This standard is a mixture of mandatory elements and elements weighted 3.  

For purposes of the desktop review coming should submit your quality management program description and any associated policies and procedures that specifically address performance measurement.  In addition, you should submit one or two summary reports demonstrating implementation of those policies and procedures, as well as a sample action plan.

During the on-site review, the reviewer will examine your full complement of performance evaluation reports.  In addition, he/she will look at evidence of how you've communicated those results to appropriate staff members.  Finally, the reviewer will interview program management staff members about two in activities with which they are involved.

The Basics

This standard requires that your organization implement written policies and procedures addressing confidentiality and security of the paper and electronic information systems.  Those policies should demonstrate that your organization:

• assesses its risks and vulnerabilities concerning confidentiality, integrity, and availability of information systems;
• prevents breaches of confidentiality and security; and
• detects, contains, and corrects violations of confidentiality and security rules.

Management Tips

Things that you can expect to include in your policies and procedures should include:

• the user access levels;
• limited access to PHI;
• the designation of the particular individual responsible for corporate compliance regarding confidentiality and security of information;
• control of computer terminals and any portable media devices;
• policies for telecommuters regarding information confidentiality and security; and
• fax machine protocols.

URAC Accreditation Tips

The risk assessment element is weighted 3; the other two elements are mandatory.

For the desktop review, you want to submit confidentiality and security risk assessments and the key policies and procedures addressing confidentiality and security.

During the on-site review, the reviewer will review your full set of policies and procedures regarding IT.  In addition, he/she will interview management and staff members about information systems, and tour and observe equipment and data centers on-site for compliance with this standard.

Management Tips

As you know, URAC has specific requirements for staff training that relate both to the content of staff training and its administration.  The Medicare Advantage component of those requirements related to confidentiality are addressed here.:

Content

Your organization must implement a training program to protect member confidentiality.

Administration

There must be documentation of all training provided for staff.

There must be a signed document acknowledging training on confidentiality issues.

The confidentiality training requirement is company-wide.  Company-wide training is typically handled either through:

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

URAC Accreditation Tips

The element requiring training in confidentiality standards is mandatory.  The rest are either weighted 2 or 4.p

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 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.

Documentation for the desktop review should include training and education program outlines and agendas across the organization, as well as any tools you use in training.

For the onsite review, be prepared to produce comprehensive orientation and training materials for selected staff members.  In addition, at any point during the on-site review, the reviewer is likely to ask the staff member about his or her training across the full scope of the standard's requirements.

The Basics

This is what I call the "mini-HIPAA" standard, even though it predates HIPAA's privacy rules.  It requires that the organization describe how Individually Identifiable Health Information ("IIHI") will be used and limit that use to those people for whom the use is necessary for business purposes.  The organization must identify who will have access to IIHI and for what purposes, to mandate anyone who might touch IIHI (employees, contractors, committee- and board-members) to keep IIHI private, and to require such people to sign a confidentiality statement.

Management Tips

Make sure your P&Ps address any personnel (employees or agents) who might have access to IIHI, whether it be in electronic or paper format.  This standard also addresses how your organization notifies consumers of their privacy rights.  

Beware of state regulatory standards that may be more restrictive than federal or URAC requirements.  Your staff members need to be trained in the most restrictive requirements, wherever they come from.

URAC Accreditation Tips

Note that this has six mandatory elements -- no getting accredited without this one!

Your HIPAA P&Ps and evidence of training on those P&Ps will suffice for purposes of the AccreditNet submission. However, one word of caution -- make sure that you don't limit this to employees. The most common mistake we've seen in our clients' applications is to have the privacy P&Ps apply to employees only, leaving out members of the governing board and/or non-employee members of committees (e.g., quality management and credentialing). Note that subsections (e) and (f) are quite specific about this.

One other thing about (f) -- this refers to patient confidentiality, not the confidentiality associated with proprietary information.  Make sure your documentation -- particularly the training and signed statements -- is clear on this point. 

The onsite review will involve an interview with the privacy officer, a close examination of signed confidentiality statements from employees, committee members, and board members, and training and other documentation regarding implementation of your privacy P&Ps.