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.