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

Both standards are weighted 3, and nearly all of the elements are primary.

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.