The Basics

These three standards set 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 time frames for the achievement of performance improvement goals
• conduct a barrier analysis if the organization does not achieve its performance goals

At all times, your organization must maintain at least two quality improvement projects (three if you are a health plan).  If your organization interacts with consumers, one of those quality improvement projects must focus on consumer service.  If your organization does not interact with consumers, that quality improvement project may address client services.  This quality improvement project must relate to one of your organization's key indicators of performance, and involve a senior clinical staff person serving in an oversight function in the case that this quality improvement project is clinical in nature.

The other quality improvement project must focus on either error reduction or consumer safety, depending on what kind of accreditation your organization is seeking.  Consumer safety quality improvement projects are mandatory for organizations seeking accreditation in any of these programs: Pharmacy Benefit Management, Health Utilization Management, Workers Comp Utilization Management, Health Call Center, Health Plan, Disease Management, Independent Review, and Case Management. This quality improvement project must focus on error reduction for organizations seeking accreditation in any other accreditation program.

Make sure you know which quality improvement projects your organization has decided it will use to demonstrate compliance with these standards.

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.

Here are a few tips to make these standards easier:

• A good place to look for ideas for QIPs are barriers to proper medical management, use of current triage guidelines, integration of quality information, patient access issues, sentinel events tracking, etc.
• Make sure the baseline and goals are measurable, and in the same units.
• Make sure your goal is connected to a target date for achievement.

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.  URAC reviewers will interview the senior clinical staff person to assess his/her involvement in clinical judgments (subsection 37(a)(iii)).

The Basics

This standard sets forth a number of requirements for written documentation of elements of the quality management program.  That documentation must address:

• evidence that your organization monitors its own compliance with URAC standards on an ongoing basis
• the objectives of the quality management program and methodologies involved in monitoring and evaluating quality activities
• your organization's key indicators of performance, along with how the organization tracks and trends its performance on those key indicators as they relate to consumer or client services
• how the organization implements corrective action plans
• how the organization communicates its quality efforts to members of its staff
• how the organization reports its quality activities to the quality management committee
• In most organizations, these documentation requirements are outlined in the Quality Management Program Description (or a group of policies and procedures that are the equivalent of a Program Description), so make sure that you have reviewed that document. 

The requirement to track and trend key performance indicators is very similar to the requirements described in the next several standards for quality improvement projects.  You should identify areas of performance that are important to the quality of your service to consumers or clients, establish your current level of performance in each of those indicators, establish performance requirements, and periodically measure your performance against those requirements.  In those cases where your organization's performance slips below your performance standard, you need to clearly document your corrective action plan, being very specific about what interventions you are implementing in order to raise your performance back to the performance standard.

Management Tips

Note that this standard is named "quality management documentation."  The emphasis here is not merely on the establishment of key performance indicators and a mechanism for making sure your organization meets those standards, but also that you clearly document every phase of that process.  Therefore, your quality management program description should clearly describe both the process of performance evaluation and the process of documenting your implementation of your performance evaluation process.

It is telling that, in the next version of the standards, URAC more clearly articulates how this should be documented.  In the new version, tracking and trending of key performance indicators looks very much like the quality improvement projects required by the subsequent standards.  Therefore, we are now recommending that you use the standardized quality improvement project description form that URAC provides for the submission of quality improvement projects.  About the only difference between this new vision of tracking and trending performance and quality improvement projects is that quality improvement projects must be designed to improve performance, while key indicator tracking and trending can have the maintenance of existing performance levels as an objective.

URAC Accreditation Tips

Two elements of the standard are mandatory: the element requiring ongoing monitoring for compliance with accreditation standards and the element requiring that you document your objectives and approaches for monitoring and evaluating your quality activities.  The rest of the elements are weighted either three or two.

For purposes of the desktop review, you will need to submit your program description and plan or equivalent policies and procedures describing how you document the various components of your quality program.  In addition, you should submit a couple of sample summary reports that describe your tracking and trending activities.  Finally, you should also submit a sample of a corrective action plan describing how you have responded when you learned of sub-par performance on a key indicator.

In addition to interviews of your quality management leadership team, your on-site review will involve examination of reports of your tracking and trending activities, examples of how you've communicated your quality activities to members of your staff, and minutes of quality management committee meetings in which the committee examined performance reports.

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 outlines the requirements for the quality management program.  The required components of the QM program description include approval by the board of directors or other governing panel, the "scope, objectives, activities, and structure" of the program, annual review by the QM committee (the roles and responsibilities of which must be described), and the identification of a single member of senior staff who oversees the QM functions while serving on the QM committee.

Management Tips

As described in a previous page, the Quality Management Program description should be able to support most of the documentary requirements for this standard.  In fact, it could be said that this provides you with an outline for that program description.  

In addition to preparing a suitable QM program description, the other essential management function behind this standard is getting the required approvals of the governing body (e.g., a board of directors or executive committee) and the Quality Management Committee.

URAC Accreditation Tips

Each of the elements of this standard is weighted either 2 or 3.

The URAC Program Guide says that all you need do at the Application stage is submit a "Program description and plan or P&Ps addressing QM oversight of the program," and your documentation worries are over.

And, for some reviewers, that may be so. However, you can save yourself the risk of a dispute over the adequacy of that documentation, and take some of the work out of the onsite review process, if you go a bit farther in demonstrating compliance with the elements requiring approval by the "organization's governing body" and annual review and approval by the Quality Management Committee.  At some point in the process, either during the desktop review or the onsite review, the reviewer will need to see documentation independent of the QM Program Description that the governing body has approved the QM Program Description and that the QM Committee, within the past year, has reviewed and approved it. 

I recommend that you do this up front, at the Application stage of the process. This should be easy -- submit committee minutes demonstrating such committee approval by both of these panels or submit signed, dated attestations from the chairs of these to bodies indicating that their committees have, as required, approved the program document, and when each committee did so.

While I usually think the Program Guide provides the best idea of what documentation will suffice for a particular standard, this is one situation in which I think it's best to go a bit farther.

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 2.

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 weighted 3.

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.