One of the hallmarks of the URAC accreditation process is the reliance on policies and procedures. Anyone who has glanced at URAC's Core standards can tell you that there is an entire standard (Core 3) dedicated to the care and feeding of P&Ps. The standards don't stop there, though, in their reverence for P&Ps: many standards explicitly reference policies, as do dozens of other standards scattered throughout the modules. I venture to say that the most frequent word used in the "Evidence for Desktop Review" sections of the URAC standards is "policy" (although I haven't actually counted).

However, if I stopped there, I still would not have conveyed how utterly important it is to have your P&Ps in order, fully reflecting the requirements of the standards. It is almost universally true that the requirements of the URAC standards must be reflected somewhere in a written policy. It seldom seems to matter if your organization's actual behavior is fully compliant with the requirements of the URAC standard. In addition to actual compliance with the requirements, you generally have to have a policy and procedure that requires that full compliance.

The rationale, as I understand it, is fairly straightforward and arguably reasonable: Just because you are compliant today does not mean you are compliant as a matter of policy. You could just be temporarily, and even accidentally, compliant. However, if you have a policy and procedure, and are complying with Core 3's requirement that you regularly review and implement your P&Ps, you are more likely to be compliant with the standard tomorrow, and tomorrow, and tomorrow.

You might argue that a flawless record of compliance (e.g., 30 out of 30 selected files are fully compliant) is demonstration that you have and have implemented a policy -- albeit a tacit one -- that complies with the standard. Save those arguments for social scientists and trial lawyers -- they won't fly here. And, probably, rightfully so.

So, the lesson to be learned here is simple -- don't rely on the mere fact that you are playing by the rules and conducting your business in full compliance of URAC's standards. Instead, play it safe and make sure all of the requirements of the URAC standards that apply to your organization are reflected not only in your behavior but also in your policies and procedures.

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.

A short (1:15) video message from Tom Goddard, Chief Executive Officer of Integral Healthcare Solutions, LLC:

The Basics

This standard sets forth requirements for the organizations documents to include not only a mission statement, but also a description of the organization framework, the target population, and general structure.  These documents no doubt exist somewhere, and it will be up to the URAC Accreditation Team in your organization to make sure they all get into the hands of the URAC reviewer.

URAC Accreditation Tips

Each of the four elements of this standard is weighted 2.

The documentation for the mission statement can be a screenshot of the mission statement from your website or a page from a printed document, internal or external.

The requirement of "organizational framework for the program" is a bit less evident, in our experience.  This language has confused clients from time to time.  We recommend a program description -- of the type often prepared for prospective clients -- that describes how your organization provides its services to clients and consumers.  It might be a marketing piece, or a template proposal, or a regulatory document -- anything that describes how you deliver services.

The element addressing the consumers your organization serve is designed to guide the reviewer as she looks at other standards, such as access and availability of services.  The reasoning here is that you cannot deliver services effectively if you don't know to whom you are delivering them.  Therefore, the description of your "population served" is likely to be in terms of demographics -- income level, literacy, English fluency, age, etc.  But if you are a national or state-wide organization?  in that case, submit documentation demonstrating that, and then reference the general demographic characteristics of the nation or the state that you serve.

The documentation for the element for "organizational oversight and reporting" is a description (narrative, organization charts, or both) of your reporting mechanisms for both staff and committees (most notably, the quality management committee).  

Most of the onsite review verification of this standard is melded with the verification of compliance with other standards, so once you get past the desktop review for Core 2, you are largely in the clear.

One of the new features of the scoring methodology in v. 3.0 is that Core will always be 30% of of the total points available for accreditation, regardless of the accreditation program.  This is a change from previous versions, when the percentage of total points allotted to Core depended upon the program.  For example, previously, Core was a smaller factor for Health Plans than it was for a single module program, such as Utilization Management or Independent Review Organization.

One of the changes in v. 3.0 has to do with policies applicants are expected to submit with their application. 

Previously, what was requried to be submitted to document compliance with standards was "policies and procedures."  URAC has changed this to allow for "written policies and/or documented procedures." 

The purpose of this change is to distinguish between policies, which provide direction and guide decision-making from procedures, which map out the steps for staff to follow to perform a particular function.  "Procedures" could include a process flowchart, escalation matrix, guidelines, etc.

URAC is starting to clarify its new Core standards, v. 3.0, which will be known as "Module I" for all the healthcare accreditation programs.  The new standards have a release date of November 2008, and were the subject of extensive interest at the 2008 URAC Summit.

Core 1-23 and 25-29 apply to all applicant organizations regardles of the accreditation program.  On the other hand, Core 30-35 apply only when clinical staff is required to perform the function covered by the accreditation.  The programs in this category are:

• Health UM
• Workers Compensation UM
• Independent Review Organization
• Provider Credentialing
• Claims Processing
• Credentials Verification Organization

Core 24 and 36-40 apply when clinical staff interface with consumers.  This includes:

• Case Management
• Disease Management
• Health Call Center
• Health Plan
• Health Network
• Consumer Education and Support

Core 13 (c) provides:

The organization implements information system(s) (electronic, paper or both) to collect, maintain, and analyze information necessary for organizational management that:
* * *
(c) Includes a disaster recovery plan that;
(i) Is tested at least every two years; and
(ii) Addresses identified areas for improvement; . . ..

Cartoonist Scott Adams, creator of Dilbert, provides a vivid example of what URAC will not accept for this standard.  Click here, and then the "play" arrow over the picture, to view the 23 second clip.

The Basics

This standard very simply requires that your staff members meet the requirements of the jobs they occupy, as described in the job descriptions required by Core 4.

Management Tips

The personnel file audit we recommend in our lengthier blog on the topic (click here) should include a check for a concurrence between job descriptions and résumés.

URAC Accreditation Tips

It carries a weight of 3, and, like Core 4, has a straightforward documentation requirement at the AccreditNet phase of the process: submit job descriptions.  You may (and should) submit the same documents you submitted for Core 4.

The difference here with Core 4 is in the onsite review: for the staff members selected from the employee directory, the reviewer will compare the job descriptions' requirements to the résumés of the respective employees to make sure that they meet the requirements as outlined in the job descriptions.  

The Basics

This standard requires URAC accredited companies to have job descriptions for all staff members.  Those job descriptions must describe required background (education and experience), required competencies, licenses, and/or certificates, and describe the jobs' scope of role and responsibilities.

Management Tips

This standard typically is missed onsite by organizations that have not set minimum requirements for non-clinical staff members.  Therefore, we recommend a complete internal audit, particularly by the HR departments of first-time applicants, of all the job descriptions to assure that they all (clinicaland non-clinical) have minimum requirements.  

One other tip -- eliminate the words "or equivalent experience."  They are, in URAC's view (and mine), meaningless.  Describe what that equivalent experience might be, and you'll be fine. 

URAC Accreditation Tips

The standard carries a weight of only 2, indicating how distant job descriptions are from consumer protection in URAC's mind.  

The documentary requirements for this standard are straightforward -- submit up to 9 job descriptions of the staff members who do the bulk of the work in the areas that are the subject of the accreditation module(s).  The onsite review is, as you might expect, a random selection of actual job descriptions, chosen from the staff directory.