The Basics

IRO Core 3 requires that your organization operate under policies and procedures ("P&Ps").  This is an incredibly important standard.  It requires several things of all employees.  First, you need to know where your organization's "master list of P&Ps" is.  If you don't know, find out.

Second, you need to be able to access -- quickly and easily -- the specific P&Ps that apply to your job.  Again, if you don't know, find out.

Third, you need to do your job in accord with those P&Ps.  Failing to do so is, itself, a way to miss this standard, even if what you are doing complies with the applicable URAC standard.  For example, if you are in the IT department performing an activity (e.g., destruction of old data) in a way that complies with the applicable URAC standard, you'll violate a mandatory element of this standard anyway if you are doing it in a way that is inconsistent with your organization's P&P on the subject.  So, if your P&P inaccurately describes the way things are done, get whoever is in charge of your P&Ps to change the P&P to fit reality.

Management Tips

IRO Core 3 sets forth a number of requirements for an organization's policies and procedures (P&P) processes.  Your organization must comply with its P&Ps, maintain a list, keep the P&Ps up-to-date through an annual review, and leave a paper-trail for each P&P of its effective, review, and revision dates, as well as who (or what committee) approves each P&P.

The standard 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 (b)'s "and complies." The effect of this phrase is to transform all your organization's policies and procedures into mandatory 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 IRO Core 3(b). And that would be very bad.  The key to documenting this is to make sure that your applicable P&P includes the method by which the organization monitors its core business operations for compliance with written policies and procedures. 

Fourth, one of the more frequently missed elements of this standard is IRO 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.

URAC Accreditation Tips

Maintaining and complying with your P&Ps is mandatory. Mess up subsection (a), and you will do no better than a Conditional Accreditation.  The rest of the elements of the standard carry a weight of 2 or 3.

In a recent clarification, URAC has modified its stand on IRO Core 3(a). IRO Core 3(a) is triggered if:

• 3 occurrences of not complying with own P&P, or
• 2 occurrences of not complying with own P&P and in both instances, the applicant organization is then not meeting a Mandatory standard element (2 [M] not met).

For the desktop review, you should submit the master list of P&Ps, including the method by which the organization monitors its core business operations for compliance with written policies and procedures, and your policy and procedure on the maintenance of policies and procedures.

The on-site reviewer will assess whether your staff can easily access the policies and procedures that govern their work.  They could do this at any point during the day, during any interview.  The question might go like this: "If you have a question about how to do a particular aspect of your job, and your supervisor is not readily available, can you access the policy and procedure that might answer that question?  Could you show me, now, how you would do that?"

The Basics

With this standard, you are required to answer the question, what services do we provide, and where do we provide them?

This standard is important to URAC reviewers, because it helps them understand the nature of your network.  Are you a general healthcare services network or specialty network?  Do you provide health care services in a small region, statewide, or nationally?  The rest of the review will be guided by the documentation and answers to interview questions that you provide in connection with this standard.

Your organization likely answers both of these questions in official documents, such as marketing documents, regulatory filings, and the geo-access maps that help you manage your provider network.  Make sure you are familiar with how your organization officially answers these questions.

Management Tips

Remember, you do not get credit for doing things that you do not document.  So, the fact that you operate in a certain area and provide certain health care services is insufficient for purposes of this accreditation process.  Rather, you need to be able to document, with official company documents, what services you provide and where you provide them.  You are allowed a good deal of flexibility in how you do this.  Your documentation might be in marketing materials, regulatory materials, internal policies and procedures or plans, or reports.

URAC Accreditation Tips

Each of the two elements of this standard is weighted 4.

Your desktop review documentation is likely to be some combination of plans (business, marketing, strategic), service area maps, geo-access analyses, and regulatory filings.

The on-site reviewer will verify your compliance with the standard through an examination of your organizational documents and interviews with network management and provider relations management personnel.

Effective October 1, 2011, the Accreditation Summary Report that URAC provides to organizations that have completed the accreditation process, has been expanded to provide more detail than ever before. The new ASR includes:

• Overall application scores
• Individual module score
• Description of the accreditation category
• Books of business excluded from the scope of the accreditation
• Locations of sites included within the accreditation
• Individual standard/element scoring category
• Terms of the accreditation
• Notes

The Basics

This standard requires that the CM program implement P&Ps that specify when the CM staff members (1) refer consumer questions and (2) initiate other communications (scheduled and non-scheduled) to ordering providers.

Management Tips

This new standard requires a rather simple, straightforward P&P that provides guidance to your staff about these two areas of communications with treating providers.  Naturally, the provider may not want to work with the CM program.  This does not obviate the need for you to have an applicable P&P addressing the topic.

URAC Accreditation Tips

The two elements of this standard are both worth 3 points.

For the desktop review, you need submit only the applicable P&P.

In addition to reviewing the P&P, the onsite reviewer will use the audit of individual case files to look for evidence of communication with providers consistent with the time frames described in the P&P.  In addition, the reviewer likely will ask the case manager(s) she interviews questions about provider communication, including:

• Do you ever communicate with the program participant's treating provider?
• How do you handle participants' clinical questions that should be addressed to their own physicians?
• What are the time constraints for referring questions to the treating provider?
• How do you document communications with treating providers?

The Basics

This standard requires that the results of the case file reviews be used in order to assess case managers' learning needs and to provide information for the required annual performance evaluation.  Whether you are a case manager or a supervisor of case managers, you'll need to know the particular connection in your company between the case file audits and case manager performance evaluation.

Management Tips

You P&Ps involving case manager performance evaluation must explicitly describe the connection between the file review process and the performance evaluation process.  Furthermore, the performance appraisal form used for case managers should demonstrate the use of the results of file audits.

URAC Accreditation Tips

This new standard weighs 3 points.

For the desktop review, submit:

• A P&P describing the relationship between file audits and case manager performance evaluation;
• The case file audit tool; and
• A template for case manager performance evaluation.

During the onsite review, the URAC reviewer will examine individual case manager personnel files for evidence in the annual performance evaluation of the use of the results of case file audits.

The Basics

This standard, new to this version, requires that all case managers be certified by a URAC-recognized program no less than 4 years after hire as a case manager.  URAC-approved certifications are listed here.

Management Tips

Only experience as a case manager counts when tabulating the 4 years.  It is important that you have a P&P that directly addresses this issue, even if you are a first-time applicant. 

URAC Accreditation Tips

This standard is a "Leading Indicator," meaning that, while it has no point value for this accreditation, it is useful to URAC if you attempt to document how you comply with the standard.  It also means there is no onsite verification.

For the desktop review, submit the applicable P&P. 

The Basics

This standard establishes requirements for the DM program’s telephonic communication system.  That system should:

• Allow the staff to receive and return calls;
• Have hours of operation that the program clearly communicates to program participants;
• Gives to those who call outside business hours appropriate instructions regarding emergency situations; and
• Have a means of documenting periodic evaluation of the system’s performance, including reporting mechanisms.

In addition, the system should operate under clear criteria that include instructions regarding

• Emergency situations
• Calls received outside the normal business hours

Not all DM programs are the same.  Your telephonic system should be appropriate for the kinds of services it provides to participants.

Management Tips

At a bare minimum your P&P and/or program description should describe a system that can receive and return calls about how the DM program operates.  It also should be very clear not only about the hours of operation, but how those hours will be communicated to consumers and what to do with consumer calls outside of those hours of operation.   You may forward such calls to a health call center or an after-hours nurse.
Make sure you have the capacity to conduct industry-standard analysis of telephonic access to services, such as

• Call wait times
• Call blockage
• Average speed of answer
• Abandonment rate.

URAC Accreditation Tips

Four of the five elements are weighted 4; the other is weighted 3.

The documents needed for the desktop review include not only the applicable P&P and/or program description, but also supporting exhibits such as scripts, call center reports, staff training agendas, or sample consumer materials that discuss the program’s hours of operation.

The onsite reviewer will listen to the recorded voice mail message.  He/she will ask for a demonstration of the call tracking system, and may ask the staff members such questions as:

• What happens when a program participant calls after your hours of operation?
• What are your hours of operation?
• What materials are used to communicate hours of operations to program participants?
• How does the program document and track the telephone system’s performance?
• Can you both receive and return telephone calls?

The Basics

This standard proposes that the DM program have subject matter experts (SMEs) review educational materials before the program uses them in the DM program.  In addition, it suggests that the medical director or his/her equivalent also review consumer health information.

Management Tips

Not only should your P&P or program description require the review and approval process discussed in this standard, but it also should outline how that review is to be documented, whether in the form of meeting minutes, attestations, or the completion of specified review forms.

URAC Accreditation Tips

The two elements of this new standard are each worth 1 point.

For the desktop review, submit the applicable P&P and/or program description, as well as any documentation of the review process (e.g., meeting minutes, memoranda, attestations).

The onsite reviewer will interview management personnel about the review process.  The reviewer also will look at recent documentation of the review process.

The Basics

This relatively new standard proposes that the DM program address not only the content of educational materials provided to participants (DM 22), but also the means of delivering those materials.  Thus, a program that complies with this standard will target educational materials based on the participant’s current stage of care.  In addition, a program that complies with this standard is proactive in providing health information, and supports informed participant decision making and self-care skill building and motivation, as well as comfort and acceptance by the consumer.  Educational materials should address consumer health literacy (see Core 40).  The information should be easy to use, accurate, and involve the use of community resources and other health care organizations.

Management Tips

This standard provides guidance useful to taking a basic DM program into a more advanced stage of its development.  Some of the components are already required by core standards (health literacy and accuracy), but some – such as the requirement that the educational materials target information needs based on the participant’s current level of care – are more cutting-edge for some programs.  One of the particular challenges of this standard will be documenting the implementation of those P&Ps that do address all these elements.  The use of community resources by the DM program is an important objective of this standard.

URAC Accreditation Tips

The eight elements of this standard are each weighted 1. 

You likely will be able to submit the same documents (P&Ps and sample educational materials) that you submitted for the previous standard.  In addition, if you have any reports of consumer focus groups, submit them for this standard.

The onsite reviewer will interview staff and management for their assessment of where the program is headed in terms of advancing consumer education.  An emphasis on growing use of community resources may be evident. 

The Basics

This important standard describes the ongoing education the DM program must provide to consumers.  That education must include:

• Topics related to self-management regarding the clinical condition and the participant’s use of clinical and educational resources;
• Materials reflecting the target participants’ learning needs; and
• Reflect evidence-based best practices.

The system used in the DM program must provide for documenting which educational materials go to the individual participant.

Management Tips

The P&P or portion of the program description dealing with consumer education should provide guidance as to which educational materials should be sent to which consumers.  In addition, it should specifically address the issue of assuring that those materials match the needs – linguistic, educational, and otherwise – of the persons to whom they are to be sent.  Those materials should be designed to help the participant achieve his/her condition-specific goals.  We recommend that the program periodically evaluate the effectiveness of educational materials in the course of broader evaluation of the DM program’s effectiveness.

URAC Accreditation Tips

All four elements of the standard are mandatory.

Submit to URAC the applicable P&Ps described above, as well as samples of both educational materials for each clinical condition and research that supports the educational materials provided to program participants.

The onsite reviewer will need to be able to see all of the educational materials that you provide to program participants, as well as evidence that those materials have been reviewed by either the program director or clinical experts.  In addition, the DM staff interviews may address such questions as:

• How do you determine what educational materials, if any, to send to a participant?
• In what way do those materials relate to the clinical and non-clinical goals of program participants?
• How do you evaluate the educational needs of the participant?