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.