The MAO must have a chronic care improvement program (CCIP).

The Basics

The URAC standard supporting this CMS standard, MAP-CCIP1, requires that your organization have a chronic care improvement program ("CCIP") that is relevant to your organization's Medicare Advantage population.  That program must use criteria that include ways for your organization to identify enrollees with multiple or severe chronic conditions that your CCIP could help.

Management Tips

Make sure your P&Ps fully describe the program and have all the elements required by URAC and CMS.

URAC Accreditation Tips

For the desktop review, it will be sufficient to submit your CCIP's P&Ps, criteria, and program evaluation.  In addition, you should submit sample data reports and examples off quality committee minutes showing that the committee reviewed CCIP reports.  Sample completed health assessments and a list of diagnoses that serve as a signal to admit MA enrollees into your CCIP should be included.  

During the onsite review, the reviewer will examine the CMS-supplied form that documents the activity of your CCIP.  He/she is also likely to review case files (as many as 30) and interview staff members to determine:

• How you identified the conditions
• Whether you admit enrollees with multiple conditions into the program
• How you inform providers and enrollees of the program
• The services your participating enrollees receive
• Your program's objectives
• What outcomes your CCIP has demonstrated

The MAO corrects significant systematic problems that come to its attention through internal surveillance, complaints, or other mechanisms.

This standard is addressed in many of the URAC quality management standards that you've read elsewhere (e.g., Core 13, 31, 33, and 34), so there is no need to repeat them here.

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 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, in addition to the QIP described in the previous two standards, you also have preventive care programs that include both preventive health guidelines that are age-specific for your organization's entire consumer base, and the dissemination of those guidelines to participating providers.  These guidelines can be either developed externally and adopted by your senior clinicians or developed and approved internally by qualified clinicians.

Management Tips

Your P&Ps on this topic should clearly spell out the development, review, and approval processes for preventive guidelines.  In addition, it will be important that they clearly mandate dissemination of those guidelines to participating providers and describe the mechanism for such dissemination.

URAC Accreditation Tips

For the desktop review, submit your P&P as well as a sample of both the preventive guidelines and evidence of how you provided those guidelines to members of your provider network.

During the onsite review, the reviewer will examine your documentation of review and approval of your guidelines, and will interview senior clinical leadership about that process.

The Basics

These standards require that at least one of the quality improvement projects ("QIPs") required by P-QM 1 focuses on the prevention of acute or chronic health conditions.  The project submitted under the Florida Addendum needs to target populations with the greatest needs and must be in an area where your organization has a good chance of improving quality.

Management Tips

Documentation will be very important, so set up a standardized way of tracking QIPs.  URAC provides a form for this purpose that captures all the essential requirements.  Also, the involvement of the quality management committee in the approval and tracking of your QIPs will need to be documented in that committee's minutes.

URAC Accreditation Tips

All you need to submit are your QIP description forms.  You may also submit QM committee minutes showing committee approval of the QIPs, although that submission can wait for the onsite review if you are reluctant to submit minutes.

During the onsite review, the reviewer will want to see QM minutes for the last three years, as well as binders/files showing full documentation on the three submitted QIPs. The reviewer also will interview your medical director and senior QM staff members about the QIPs.  Have a PowerPoint presentation that summarizes your QIPs.  The essentials for that presentation are:

• definitions of measures (clear descriptions of the numerator and denominator of any fractions/percentages you provide)
• baseline -- date and measure
• goals -- in the same units of measurement as the baseline measure
• time line for achievement of goals
• interventions
• remeasurements.