URAC Core 3 -- Policy and Procedure Maintenance, Review, and Approval

Core 3 provides:

The organization:
(a) Maintains and complies with written policies and procedures that govern all
aspects of its operations;
(b) Maintains a master list of all such policies and procedures;
(c) Reviews policies and procedures no less than annually and revises as necessary;
and
(d) Includes the following on all policies and procedures:
(i) Effective dates, review dates, including the date of the most recent revision;
and
(ii) Identification of approval authority.

There are several things to note about this standard. First, it is mandatory. Mess up subsection (a), the only primary element of the standard, and you will do no better than a Conditional Accreditation.

Second, it applies "to the key services and internal programs established by the applicant. For purposes of accreditation, the policies and procedures that cover primary health care-related program services will be examined for compliance with these standards." So, while its scope is broad, many organizations will have a number of policies and procedures that are not affected by the requirements of the standard. As the Program Guide notes, "Policies and procedures covering general personnel, accounting, office management, and other such support services for the organization are not required as evidence for meeting these standards."

Third, mere maintenance of policies and procedures will not suffice. One of the most powerful two-word phrases in all of the URAC standards is subsection (a)'s "and complies". The effect of this phrase is to transform all your organization's policies and procedures into accreditation standards. In other words, even if you are complying with a particular URAC standard, if you are not in compliance with your own policy and procedure on the topic, you may run afoul of Core 3(a). And that would be very bad.

Fourth, one of the more frequently missed elements of this standard is Core 3(d)(i). While it may not be evident from the language of the standard, "review" and "revision" can be two entirely different events happening on entirely different dates. For example, if you review a policy without revising, your policy and procedure and/or your master list of P&Ps will need to indicate both dates, not simply the most recent day that somebody in authority looked at the policy. Therefore, either your P&P or your master list should have one place for the effective date, another place for the most recent revision, and another place for the most recent review.

So, don't merely mind your p's and q's, mind also your P&Ps.