Accreditations Do's and Don'ts

Join our insightful webinar as we delve into the ins and outs of the accreditation process with our team of seasoned experts. Led by Dr. Thomas Goddard, CEO of Integral Healthcare Solutions, alongside IHS President Lesley Malus Reed and CCO Susan DeMarino, this dynamic trio boasts an impressive track record, having meticulously assessed and guided over 2,500 successful accreditation campaigns spanning two decades.

In this virtual discourse, they provide comprehensive coverage on vital accreditation aspects, including:

1) Strategic timing strategies for your Accreditation Agreement completion

2) Improving documentation around policies, procedures, dashboards, meeting minutes, and more

3) Leveraging effective project management tools for a seamless process

4) Navigating corrective action plans

This webinar was originally recorded in June 2020 and was updated in August 2023.

See more educational accreditation-related videos here.

Transcription

[00:00:10.160] - Thomas Goddard

Hello, wherever you are. And welcome to this webinar. My name is Tom Goddard. I'm the founder and chief executive officer of Integral Healthcare Solutions. And today, my colleagues and I will be presenting a webinar on the do's and don'ts of accreditation, tips that will help across all accreditation platforms and frankly, across many accreditation programs, although we'll be specifically speaking more toward URAC than other accreditation programs. But these are generally good ideas across that whole world.

[00:00:44.450] - Thomas Goddard

Let me introduce ourselves, and then I'll talk a bit about the company, and then we'll get straight into the webinar. Let me toss it to you, Lesley. Tell us who you are.

[00:00:55.430] - Lesley Malus Reed

I'm Lesley Malus Reed, I'm President of Integral Healthcare Solutions. I started in the Canadian healthcare system, worked for one of the Mid-Atlantic Health Plans, and then I joined URAC as a reviewer in 1997. In 2003, I thought it would just be more fun getting applicants ready. So that's what I've been doing with Tom and later Sue since then. Sue?

[00:01:20.410] - Sue DeMarino

Hi, I'm Sue DeMarino. I am a registered nurse. I'm the chief clinical officer at IHS. I started my career in the accreditation area with URAC in 1999, and then I joined Tom and Lesley in 2015. And so I'm really happy to be here today to talk to you about the do's and don'ts. Tom?

[00:01:49.240] - Thomas Goddard

Thank you, Sue. My background is in law and psychology. I went to URAC a little bit after Lesley and a little bit before Sue back in 1998, late 1998. I served there as the Chief Operating Officer and General Counsel and also as a reviewer for a couple of hundred different reviews over that period of time I was there, and then founded this company in 2002, Integral Healthcare Solution specializes in helping health care organizations achieve and retain accreditation. And in addition to that, because of the obvious connection, we also help some organizations with their general compliance issues. But we are a specialized firm for accreditation, and we serve applicants for accreditation across most of the health care platforms: URAC, Joint Commission, Specialty Pharmacy, ACHC, NCQA, and VIPPS, at least those are the ones that pop to mind. Let me share my screen now, and we'll just jump right into this. So I'll take this first section, contracting. And this piece of contracting is before you even start your process, you've got to contract with perhaps consulting firms, us, or one of the other consulting firms out there. And the reason we put that before you're completing your contract with URAC is if you're a first time applicant and you don't know how prepared you are, for some organizations, it's been quite useful to start that gap analysis process, which we'll talk about later, before you actually complete your agreement with URAC or the other accreditation firms.

[00:03:49.170] - Thomas Goddard

Because at least with URAC, there's a time the clock starts ticking, and you have only a few months after you sign your accreditation agreement to submit your documents to implementation. And you may find in your gap analysis that you have more than, let's say, six months of work to do, but URAC will give you six months. And they've been shortening that lately, so you have less time than accrediting applicants from previous years had in order to get your documents in. So particularly for first time applicants, think carefully about when you're going to contract with IHS or another consultant, and when you're going to contract with URAC. If you're a re-accreditation organization, as you know, URAC is in charge of your time schedule, so you'll sign the accreditation agreement when it's time to sign the accreditation agreement in order to prevent your accreditation from lapsing. One of the things that you'll need to be able to draw the distinction between in your dealings with you're at is the difference between your relationship with the sales manager and your relationship with your account manager. The sales manager is the person at you're at that helps you sort out things about having multiple sites because there are different fees attached to that.

[00:05:03.550] - Thomas Goddard

So you want to get as much of your business model into the hands of the sales manager as you can, so that anything like multiple sites or remote sites can be sorted out early. It's a lot easier to do it at the beginning than in the middle. Now the account manager has a different set of functions. They serve as the go-between between you and you're at the substantive level, and particularly that's the person that you should go to to request any extensions. If you should have a strange thing happens that doesn't allow you to submit on time, there's a whole process to go through for requesting and receiving extensions, and that's handled at the account manager level. So the sales manager won't be able to help you with that. So I will toss it to you, Sue, for the next piece.

[00:05:57.510] - Sue DeMarino

Okay. The other thing that's really important for you to understand is the two pieces of information you have to provide to URAC. Part one, I like to call the demographic information, is submitted at one time you could submit part one and part two together. URAC no longer does it that way. And the reason why I'm bringing it up is sometimes when you submit the demographic information, it also includes things like your organization's legal documentation, licensing information. It requires you to identify who your senior leadership is, whether you do any delegation, things like that. Well, at times, you may find that the information is not clear enough and they may request additional information. That's what an RFI is. It's a request for Information. And sometimes it can take 2-3 weeks before they finally approve the part one of your application. Why am I telling you this? It's because you cannot upload the part two, which is the documentation submission, to URAC until part one has been reviewed and accepted. So, for instance, if you don't start this process early on, let's say your desktop review is due next Monday and you didn't start it till this Monday, you may miss your time frame if they request additional information.

[00:07:37.030] - Sue DeMarino

So I would encourage you to complete the part one as soon as possible so that it's over, it's done with, and you know that you're at has accepted it. And then part two, we often refer to that as your index date. And in your contract with URAC, they're going to tell you, as Tom mentioned a little while ago, the actual date that you have to submit your documentation. And what they're expecting to see are your policies, procedures, workflow, supporting documents. But one of the things that you need to be aware of is that there's a limit of 10 unique documents per standard.

[00:08:25.450] - Lesley Malus Reed

I'm going to talk about the gap analysis. The first thing that you should be doing in your gap analysis is really just identifying a lead, a lead who's going to shepherd you through this, make assignments, break down the standards and see who should be the subject matter experts for those areas and and Tom's going to talk more in-depth about human resources in this process. But once you have those people assigned, now it's time to dig into your accreditation guide and review your standards. You have the standards and you have the accreditation guide. I like to look at the standards as a law. Here's the statement of Law. Then the accreditation guide has the interpretation of the law, meaning it has interpretive information, commentary. It defines the scope. It gives you points to remember. As you do a gap analysis, standard by standard, you're going to want to dig in, take a look and make sure you have an understanding of it, review those accreditation interpretation information in URAC accreditation guide, and then start doing a gap of finding out what do we need to submit here. There is evidence for desktop review that URAC defines for you.

[00:09:41.410] - Lesley Malus Reed

And in that evidence, it almost always asks for some type of formalized document, such as a policy procedure or an org chart. And then from that point you start looking at, well, is there also supporting documents that we need? Once you've identified what you need to submit, that's the time to figure out. We do have a policy procedure, for example, the applicant, our applicants do have policies procedures. Now, what as an applicant do we need to work on to make sure it's going to be Yorah compliant? When we at IHS work with our clients, we do a deep dive into the intent of the standard. We explain what needs to be submitted, and then we speak with our applicants about what it is they need to work on to develop those materials. So I will encourage you to take a look at your accreditation guide to help you identify what your gaps are. Tom?

[00:10:43.900] - Thomas Goddard

I'll just add one more thing to what you were talking about, Les, and that is those of our clients that work with us also have interpretive information available to them in the form of tips and tricks. They are not just a regurgitation of the URAC interpretive information, but they are also an updated version of it, because we are constantly watching review or interpretations of standards. If they start to interpret a standard slightly differently or start requiring a document, let's say, at the desktop review stage, as opposed to the validation review stage, we make a note of that in our interpretive information called tips and tricks. Those of you who are our clients, make sure you check that as well as you're figuring out what documents to submit. I want to talk very briefly about accreditation management. This is a complex project. Going through accreditation isn't like walking down the hall, going from room A to room B. It involves a lot of moving parts, even for the simplest of health care organizations. I use us as an example. We are certified under URAC organizational management standards. And even that, which is a subset of those standards that you all would be going through, even that would involve all hands on deck.

[00:12:04.800] - Thomas Goddard

And so managing the process is a thing. When we started doing this work two decades ago, we used spreadsheets, and that's still spreadsheets are wonderfully flexible and useful. And if that's what you've got, that's what you've got. We ultimately evolved out of that and created what you've already heard us talk about it, but that's a software application, online application called Goldfinch, in which we have all of the standards, all of the interpret-type of information, both from you and from us, as well as template policies and procedures, external links to hyperlinks to useful resources and so on. You might want to use your organization's documents and project management software as well. Just make sure you've got a good system in place and don't presume that this is going to be handled on pieces of paper very easily, at least. And then the team, how should we think about the team that you're going to have doing this? First of all, you're going to want one or more dedicated leaders who are clearly identified as being responsible for driving the process forward. And those folks or that person need to have the full endorsement of the most senior leadership in the organization.

[00:13:18.090] - Thomas Goddard

Having that buy-in from leadership to the activities of your dedicated leaders is going to be critical. For example, let's say a document is needed out of the IT department. We need a report, and the IT department says, Yeah, but we're doing this data run over here. We can't do the report not until three weeks from now. Without the buy-in from senior leadership, those requests are likely to fall on dead ears, particularly in busy times. And so an acknowledgment by senior management that not only is this process important, but that suggests that the leaders have some say in how to distract people from their regular jobs. This needs to be a part of the regular job. And this leads into the notion of a team approach. The team is the whole company, at least that part of the company that's within the scope of the accreditation. You won't do very well if you've got an accreditation team over here who is seen as being solely responsible for the accreditation process, because accreditation is of your whole organization. You're going to need to make sure that the policies are written properly. You don't want this team over here doing that.

[00:14:33.540] - Thomas Goddard

You want people in the departments doing it, and you want to make sure that those policies are implemented properly. Again, that's not the responsibility of the accreditation department or identified dedicated leaders. No, everybody's got to be on board with that. And then finally, make sure that you've got somebody identified as doing a quality check for each of the documents that is going into the process for URAC-review to make sure that you're uploading the documents that you want. So I will turn this over to Sue.

[00:15:10.090] - Sue DeMarino

Hey, I'm going to continue talking about the desktop review, that part two that I was speaking about earlier. So now you're developing your policies and procedures, you're adding citations and things like that. A common mistake that people make is that they will reference a policy, a document, a workflow in the cited area that they've told URAC demonstrates that they're in compliance with this standard element. Well, if you're referencing a policy in the cited area, you must also submit that reference policy. So please remember that you now have a requirement to review your policies and procedures at a minimum of at least every 36 months. So you're going to define in your policy what that time frame is. I want you to be very cautious and making sure that you're complying with what your policy says, okay? Because URAC will hold you to whatever your policy says. The other thing that's sometimes missed is that organizations will take the standard, they'll copy it into a word document, and then they'll add narrative that describes how they believe they're meeting the intent. That is not a formal document. URAC will not accept it. They also do not accept draft documents.

[00:16:32.140] - Sue DeMarino

They have to be finalized, formal policies, procedures, workflows. And also you want to make sure that your policy on policies and procedures and how you're formatting it is compliant. I will tell you that some of the accreditation bodies have very, very specific requirements of what needs to be on a policy. So, for instance, if you were seeking VIPPS accreditation, you have to give your address on your policy and procedure. You have to identify the name of the person that is the approval authority. URAC, on the other hand, only requires you to identify who the approval authority is, meaning the title of that person. And you want to remember that staff, regardless of which version of standards that you're seeking accreditation under, your staff must have access to a master list for ease of finding whatever they need to look at. So the other thing I wanted to speak about is not only policies and procedures, but supporting documentation. URAC oftentimes will require you to submit meeting minutes, dashboards, so from a quality perspective for your performance indicators. So making sure that you have a mechanism to be able to demonstrate that you're tracking and trending that information.

[00:17:58.280] - Sue DeMarino

Dashboards are very helpful. Depending on which version of the standards you're under, you may or may not have quality improvement projects. And so you'll want to include those if it's a requirement. Reports, analysis, things like that, they're expecting to see marketing material, review and approval, a code of conduct under the new version of the standards. You have a business code of conduct, you have a healthcare ethics component, there's business continuity testing requirements, there's risk assessment requirements, and then any attestations where a standard is not applicable to your organization, an example of that might be in the pharma world. If you do no compounding, you might submit an attestation letting URAC know that you do no compounding. And again, attestations need to be on company letterhead, need to be signed and dated. And then when URAC's coming out to do their validation review with you, you want to make sure that you update those attestations to let them know that this is still a true fact that you are still not doing compounding. Tom, next slide. Okay. All right, version control. This is an area where I've seen organizations really struggle. It doesn't happen often, but when it happens, it's almost catastrophic because they have multiple versions of the same policy and procedure.

[00:19:33.490] - Sue DeMarino

And so you want to make sure that there's no conflict between your policies and procedures and that you do not have multiple versions of the same document. If you contract with IHS, our system has, our Goldfinch system has a replacement function. So when you update the policy, you can replace it in your document library, and then it updates it in every standard and element where that policy is attached. So that's a really nice feature. That is not a feature in URAC, Accreditnet. So it's really important that you want to make sure that you have the right version of your policies and procedures. Now, when submitting to Goldfinch if you're a client of ours or to a Accreditnet, which is URAC system, you want to make sure that you provide good citations so the reviewer knows exactly where to find the information that demonstrates compliance. A good citation, from my perspective, is a page number, a section number, a subsection number that drives it right to it. Again, if you're a client of IHS's and you're using our templates, we provide comment boxes that identify which standard applies to what section. You can then use those comment boxes to define your citations.

[00:20:55.360] - Sue DeMarino

Bookmarking is another option that you can do. Some organizations like you do highlight and bookmark. So depending on which accreditation body, there may be a little nuance, changes that they may wish to see. And then finally, communicating with your consultants if you're using consultants. So, for instance, if you have a question about a specific standard, you can either email them. But again, if you're our client, you can ask the question right within our Goldfinch system. It's tied to the specific standard. And then you can go back and reference it later to say, Oh, what did Sue say about cold chain, for instance? Well, you can go back to the cold chain standard. The task, the original question that you asked is there as well as my response. And now I think I'm going to give it back to Tom.

[00:21:55.470] - Thomas Goddard

So at this point in the process, you've now submitted. The way it works with us is we go through our whole consulting process one standard at a time. And once we have signed off and you have signed off on all the standards, you hit the Submit button, and then things start to happen. Once you hit that Submit button, it'll upload to you. What we do is we upload your documents from Goldfinch to Accreditnet. And once we've completed that, then you hit the Submit button. Post submission, several things will happen. First of all, you'll receive the names of the reviewers who are on your review team. I can be up to as many as three, or if they're training someone, even four, as one of our clients is seeing reviewers, or as few as one or two, depending on the program. So only at that point will you actually find out who your reviewers are. And they may not be the same people who did your desktop review process. At that point also, your reviewers will want to schedule a call with you. This is an important call. Do not skip it. It's an opportunity for you to just talk with the reviewers about your business model and your structure, and to raise any particular issues that they might be interested in hearing, such as acquisitions, recent management changes, whether you have multiple facilities.

[00:23:17.130] - Thomas Goddard

Sometimes one of our pharmacy clients will, between the time that they signed up with URAC and the time that they've submitted the documents at a facility, We opened up a new pharmacy down on the Southeast side of town or on the other side of the state. Well, these are definitely things that you're going to want to raise here. If you haven't already raised them, as your contract might have required that you do earlier in the process. But certainly by this point, you should let the reviewers know about any of these strange things. Or if you've got a little micro office, a hundred miles from your main office that does certain functions that may or may not be part of the accreditation, this is exactly the time to talk through how that process, how these features of your organization are going to impact the accreditation process. You don't want surprises for the reviewers in the final stages. You want them as early as you can identify to be out on the table. This is also an opportunity in this call to begin the conversation with Yrek about timelines. They'll say something like, Oh, you're going to get your RFI, your request for information, which we'll talk about later, in about five weeks, and let's schedule our validation review date or dates.

[00:24:29.040] - Thomas Goddard

So it's, as you can imagine, a very key call. So I think we'll now bounce this to Lesley.

[00:24:38.390] - Lesley Malus Reed

Thank you. So I don't want anyone to feel insulted about the request for additional information. Whether this is your third time going for accreditation or your initial, you're like almost always ask for clarification. So I want you to be prepared for request for additional information. We're going to do another gap. We're going to review what the comments are. They're going to send you an email. Your lead reviewer will send you an email saying we've completed your desktop review application and we need some clarification. Go into a credit net and download the score sheet and the score sheet will list all of the standards and whether they're met or not. If they're not met, it'll describe what the issue was and what URAC recommendation is. Now it's time to complete that gap. There are several reasons why they need clarification. Sometimes they really just miss the intended language and your policy procedure, for example, is absolutely compliant, but they missed the area you wanted them to review. So maybe that's one of the reasons. Another reason is that even though you're a reaccreditation applicant and you're coming through for...

[00:25:51.800] - Lesley Malus Reed

Your reaccreditation on the exact same standards as last time, the same version, and the standard hasn't changed one bit, sometimes the interpretation has changed in the last three years. They'll want you to make some changes. Finally, you may have made a mistake. Maybe you submitted the wrong issue, wrong document, or maybe you really didn't meet the intended expectation of the URAC reviewer. What we do at IHS is we complete a gap analysis, and we like to know and track the issues as a quality metric. Did we miss this? Did we give you faulty advice? Is it a new interpretation? These are really important things so that you can help yourself get prepared for your implementation of these standards compliantly. When you are getting ready for your RFI and you're going to resubmit these documents, you need to change the name of the document. In that very first scenario that I gave you where you submitted a compliant policy, but they missed the intended language, you need to resubmit that exact same policy, but change the title to add the letters RFI to it. So the title would now be RFI policy procedure XYZ. That's how you will know where in the system it is and how to review the information.

[00:27:21.990] - Lesley Malus Reed

If you're one of our clients, it's the same thing. You'll resubmit it to our Goldfinch platform and we'll be able to review the and intended information with the citation for exactly where you want us to review it. Finally, when they are going to give you this RFI email that says, we've completed the RFI process, I'm sorry, the desktop application process in this time for an RFI, they'll offer you a call. They'll say, let us know if you want to call. Please do take that call. Can I have the next slide, please? It's very important to pay attention to the time frame because when you get that email from them letting you know that the desktop application is complete, the time starts ticking now. You're only going to have 30 days to respond to the RFI. This is in the email where they offer you that call to go over the RFI. Always take it and it'll be scheduled usually about five business days after they sent you the email. That's when you want to complete that gap and prepare your sofa the calls so that you can say to them, we're thinking about submitting this for the RFI.

[00:28:41.280] - Lesley Malus Reed

Would that meet your expectations? So it's a really good time to have that conversation. Also to run by that issue where they had the complaint language and misintended language, you can read it to them and they'll say, Yes, that does meet it. Please just resubmit the documents that again you will title RFI policy procedure XYZ. So in your first RFI, you have 30 days to respond. Sometimes they'll request a second RFI because they're not going to complete the validation review until they feel they have your documentation demonstrating compliance. So in the second RFI, you have 10 days to respond. And you'll do the same thing. You have a gap analysis, request a call if they'll give it to you and resubmit. And then finally, you can request or they might provide you with a third RFI. Sometimes they'll just let you submit information, no problem. But sometimes they'll ask you to pay a fee for a third RFI if there is a significant amount of work left to it. All right, I'm handing it back now, I believe, to Sue.

[00:30:00.550] - Sue DeMarino

No, to Tom.

[00:30:01.820] - Thomas Goddard

That's to me. And I'll just add one more thing about the RFI, and that is if that looks for you first time, or is that looks imposing the three rounds? That's actually the exception, not the rule. Most of our clients have only one RFI. The clients that have more than one RFI are those that ignore what we advise them to do. Generally, if our clients pay attention to us, they get one RFI. So don't be scurred. Let's talk a little bit about the validation review. The validation review, and I'll speak specifically from the URAC context, but it's not all that different from the other organizations we work with. Validation Review is the accrediting organization's opportunity to validate that what you said you do in your policies and supporting documentation is, in fact, what you do. And they do that with two basic mechanisms: the interview of staff and management and review of documents. Historically, back when the three of us started, it was entirely on-site. In recent years, URAC has been weaving in a virtual component so that a good number of the modules or sections of modules were handled virtually, and some still on site in these times of the pandemic.

[00:31:24.440] - Thomas Goddard

It's entirely virtual now. So URAC itself, and we and our clients are all of learning how to do things virtually that we didn't have to do in previous years. So it's going to be really important that you review your agenda for requested documents. What does that mean? The URAC agenda starts out with a nice introductory letter and then a list of documents that the URAC reviewers want. Some of those, and it's a rather long list for many of the programs, some of those are actually documents that are logs from which the reviewer will select files to be reviewed. So, for example, a privacy breach log, if you have 50 privacy breaches over a one year period, then they would want to log so they could select maybe a 10, or if you're a health plan and you give them one of the documents listed will be a provider directory that can be used for both the credentialing and the contracting parts of the health plan standards and the network standards. And so you may want to work out, if there's going to be document pulling, you may want to figure out, work out ahead of time.

[00:32:46.350] - Thomas Goddard

Perhaps you can do the document pull for those maybe a couple of days in advance of the actual validation review. This is one of those logistical things you definitely want to talk to your reviewers about. The rest of the documents and the bulk of the documents listed there are documents that the reviewers are going to expect to be able to be shown during the validation review. So don't ignore that. One of the things that has happened over the 20 years we've been doing this is that we have seen a number of times where the applicant just completely ignores the document section and goes straight into the review, but the review involves the review of documents. So make sure that you have access, ready access with second access, maybe a hyperlink access to each of the documents requested. So if a reviewer like covering the standards I cover, for example, which include IT, if I were to say to you, I'd like to see the most recent example of your business continuity plan test, give me an executive summary of that. That person being interviewed needs to be able to pull that up on the screen in a shared screen and show it.

[00:33:56.980] - Thomas Goddard

So pay very close attention to the requested documents. URAC also provides a sheet of tips for a successful review and agenda activities. So pay attention to that. They really express the reviewers's preferences to help you go through it smoothly. If you're working with IHS, we have our own version of that that has even more suggestions for how to make it go smoothly. Whether you're working with us or not, just make sure that you get all the documents ready to be shown. There will be tours for some applicants, depending on the program you're applying for. For example, pharmacy. You're going to need to work out with the reviewers how you're going to do a pharmacy tour virtually. Why would they want to tour your pharmacy? Well, they want to make sure that you're storing your drugs properly, that you have eye-wash stations. And they're also, for example, eye-wash stations is a good example. They'll also just want to ask a random staff member in your pharmacy, Where is the eye-wash station here? And if they don't know, that's a problem. So the tours are an important part of some of the accreditation programs. And all applicants that deal with PHI are going to be subject to a tour that gives the URAC reviewer a sense of the caution that your organization brings to the protection of the confidentiality of protected health information.

[00:35:24.220] - Thomas Goddard

And I will toss it to Lesley for the 12 tips.

[00:35:27.170] - Lesley Malus Reed

Thank you. These are the tips that we share with our clients at the end of our mock validation review. It's just to help you prepare for URACual validation review with URAC. They're simple tips, and I'm going to start with number one, which is obvious, but it's usually a problem. We want you to be on time, but be very flexible with your time. URAC might need to go into meetings earlier or later, and they're also flexible if you tell them that your medical director, for example, has a meeting that he has to take, then they will fix the agenda. But for those scheduled meetings that you have, please, if it is an on site, bring lunch onto campus. Don't let anybody leave the campus for the day. If it's virtual, same thing. Make sure that you're not going to leave and run errands. The name of the game is to get the reviewer out early. If things are going quickly, then they finish the review quicker and that's an indication that things are going well. Bring props to your interviews so that even if you've already submitted that business continuity plan that Tom mentioned, you can bring it up as you speak about your information on it.

[00:36:46.030] - Lesley Malus Reed

And what I mean is that the reason I'm telling you this is that, URAC is going to have their computers in front of them and they're there to check off their boxes and they have document review to complete. But if during the conversation you bring up the business continuity plan and the minutes that show discussion of the business continuity plan, well, that helps them check their boxes and they won't go into the business continuity plan and dig deep into it. This is really good also for your quality management interviews. If you talk about the metrics, they're not going to spend as much time digging through your minutes to find things. It not only speeds things along, but if there's something in your minutes that could potentially raise a flag or affect something negatively, then they're not going to spend that time digging through your minutes to find things. You've already showed it to them with your props. Number three is to have a positive attitude and try and imply that everything here works really well. What you don't want to do, you don't want to revert to before our IT systems were not so great, and now everything is fixed.

[00:37:54.900] - Lesley Malus Reed

Just mention that right now everything is working great. If you are new to your position and things were dropped by the person before you, you really just want to talk about how things are going well right now. If, of course, you're asked you questions, you are welcome to say, That's before my time, but this is what we're doing now. Number four is, this is an open book test, and we don't want you to be afraid of turning to a colleague and asking for help to answer a question. This is definitely a call a friend, open book test. I always use the example of when you watch Jeopardy from your couch, it's very easy to answer those answers that Alex is giving you. But if you are under the spotlight, you get nervous. Some people don't always test well. So calling a friend and having the policies with you are absolutely fine. It is not cheating. It's part of the process. Number five is to only answer the question that the reviewer is asking. Tom is a lawyer. He'll tell you to try and make this like a deposition. Just answer that question and nothing more.

[00:39:07.860] - Lesley Malus Reed

And if they ask you more, that's fine. But if they're not getting their answer from you, URAC will definitely ask the question again in a different way in order to extract what they need. The reason is we have lots of stories to tell and this isn't a time issue. This is really we don't want to tell a story that again, could take us down a path that could unintentionally affect another standard negatively. Next slide. Thank you. Number six is always ask these two very important questions. One is, did I get 100 %? So first of all, if you ask that question, the reviewers will know that you got this tip from us and it'll make them laugh. But more importantly, the reviewers cannot give you what URACual score is. You're presented as a blinded application to a committee that is going to make the final decision and they will ask the reviewer some questions about your application and how you responded to things. But it's not the reviewer's decision to make your accreditation decision, your full accreditation, your conditional accreditation, corrective action, denial. Those are the four decisions. But if you ask your reviewer at the end of each interview, did I get 100 %?

[00:40:27.650] - Lesley Malus Reed

They can give you a bit of a highlight of how you did. They might say, Yep, you did really well, or I would give you a full on this. You got 100 %. Some of them will even answer. Number two, this is the most important question. After every interview, please also ask, is there anything outstanding that I owe you? So the reason for this is that you begin your interview. It's 45 minutes long. And at the very beginning, the reviewer will say to you, I'd like to see that log. And you will say, okay, I'm going to get it for you. And you continue the interview and 45 minutes later you're shaking hands or nodding on the virtual and things went really well and it's over and the reviewer leaves. But once the interview is over, the URAC reviewer will be at their desk scoring you without that outstanding item that they needed. Which leads us to number seven, we recommend that you have a shadow for each interview, someone who's taking notes that's not answering questions so that they can write down anything that the reviewer might be asking for. Maybe you need to get some information while that person said, I'll get you that log.

[00:41:43.250] - Lesley Malus Reed

That person could probably email someone right away to get that log. So it's really important to have that shadow. Number eight, seniors who are going to be interviewed. You're going to have seniors that are interviewed and you're going to have front line staff. Senior that are interviewed, we want to make sure that they not only review the standards two weeks before the URAC reviewers come, but also what you submitted for those standards so that they remember the context and the content of how you answer the standards. That way the questions will be familiar and you'll remember by reviewing these policies how you answer them. I mean, marketing, they always do such a great job and they're such extroverts and great at what they do and they're able to answer the questions, but sometimes they're answering outside the scope of what the policy procedure says. So that's why we want everybody to review the standards and what you've submitted for them. Number nine has to do with not only your seniors, but your front line staff. All staff who are interviewed might be asked the following questions around these topics. And so we want you to be able to review training to before they come to do the validation review on these topics, HIPAA and Hi Tech.

[00:43:08.120] - Lesley Malus Reed

So everybody gets HIPAA training. Everybody remembers that. But sometimes when we sit with front line staff during the mock desktop review and we say, are you familiar with high tech, they get that deer in the headline, headlines type of look. Even though you may have completed such training a month or two before, it's for some reason staff freeze up about that one. Two weeks before you're at comms, that's one of the things we recommend you review so that all staff can answer, yes, I'm familiar with it. It doesn't have to be a long answer about the Omnibus Act. It can just simply be it's part of HIPAA. That's the electronic version of HIPAA basically. It has to do with PHI. Examples of conflict of interest. So when your access to frontline staff, they're going to say, Can you give me an example of a personal conflict of interest? And most people will answer, I want to make sure that I don't have or a family member doesn't have a personal interest in the organization. If we do, we would certainly disclose that. The other example that URAC is looking for when it comes to personal interests is for people to say, if I have a file that's someone that I know, so for example, in U.

[00:44:14.510] - Lesley Malus Reed

M, if the patient is someone I know personally, I need to abstain from that file. If it's in credentialing and it's a provider who's my neighbor, I should be, as a credentialing specialist, abstaining from completing that file. The other question is, do you get a bonus? You should get everybody comfortable with answering that. They're going to ask everybody about that question, and it can get uncomfortable with some people do and some people don't. It's fine if your organization gives a bonus. What you're actually looking for is the answer, we may or may not receive bonuses, but the bonuses are not based on incentives that are based on a consumer's utilization of care that can compromise their health. The other topic is, how would you respond or handle the distressed caller? And that has to go to everybody in the organization, not just your customer service reps, not just your U. M. Folks. If you're doing U. M. Accreditation, it's for everybody. The history behind it is that during one of the validation reviews, a call kept going to a boardroom, and so it became clear at URAC that anybody could pick up a distressed caller.

[00:45:30.770] - Lesley Malus Reed

The distressed caller is defined to somebody who is either in clinical distress, meaning they could be having a heart attack or an allergic reaction, might harm someone or may harm themselves. And you want to make sure that staff will answer a consistent story of saying, we never put that individual on hold. We flagged somebody else in our organization to dial 911 for us, and we remain on the call until 911 arrives. That's what your next expectation is. No one's put on hold and no one's transferred. And finally, the other answer that is very often missed during our validation reviews is we ask front line staff if they're aware of the quality department's initiatives. Can they talk about QIPs? Do they know about any of the projects going on? So make sure that you have a mechanism, whether it's sharing minutes or having meetings that will go to staff so that they're aware of the initiative. All right. Number 10, any attestation that you're signing, Sue talked about an attestation earlier that could, for example, perhaps the bonuses are not applicable and you're going to sign an attestation saying we don't provide bonuses that would negatively affect the consumer's care.

[00:46:49.280] - Lesley Malus Reed

You want to make sure that you resign your attestations for the date of the validation review, because if you submitted your desktop application that part two in April and they're going to do the validation review in August, you want to make sure to tell them that still from April to August, this is still not applicable. Make sure it's signed and dated by a senior management representative on letterhead. Number 11, if you're asked to take a document with them, be sure to make a copy of it to keep for yourselves and de-identify any PHI on it. If they're taking it with them, it's usually an indication that they want to bring a question to their team back at URAC. It could be an issue and you want to know what that issue could be. Let's say there is a UM file in question. You cannot prove to URAC any... And you go and you go into a corrective action decision because of this UM file based on the information they took back with them. You can't prove that something after the validation review happened to show compliance. You must know what it is they took with them so that you can try and investigate it and find any missing information occurred before that date.

[00:48:09.320] - Lesley Malus Reed

You want to make sure that you have everything that they're asking for in order to defend it upon, God forbid, an appeal. We'll talk about that soon. We'll talk about corrective actions. Number 12 is create tent cards that identify your index dates, your desktop review, and your RFI submission date, because you want to be able to show that anything that happened before this date is grand fired, especially for new applicants. Let's say you have to demonstrate primary source verification for clinical staff whose job descriptions require it, and you have someone who's worked there for nine years, and this is your first time applying. You don't have to demonstrate nine years ago you did this. But anybody hired from your submission date forward, you need to be able to demonstrate implementation of that standard. So it's important to know what your index dates are and your RFI submission date because maybe you changed something to now become compliant from that date forward. It looks like we have some questions before I send it back to Sue.

[00:49:14.650] - Sue DeMarino

Okay. We can talk about performance measure reporting and how it aligns with reaccreditation.

[00:49:24.450] - Lesley Malus Reed

As you.

[00:49:25.040] - Sue DeMarino

May remember, those of you who have received accreditation, if you get accredited in 2020, January first of 2021, you have to start collecting the data. In 2022 is the first year you would report it. I believe it's every October first, URAC updates the measures requirements document that tells you very specifically what needs to be included, like how you're to gather your data, the report writing, things like that. The other thing you need to know, depending on the module that you're seeking accreditation for, you may have to have an outside entity review the validity of your data gathering. So organizations like a test is one that comes to mind. You're on their website list those data validation companies that they approve and they're deemed to be appropriate to review data validation. There is a fee for the data validation company that you'll have to pay, and I believe it depends on the volume of data that they're reviewing. There's also an ISCA form. It's an information form that talks about your system and its capabilities. That has to be complete. They used to require you to submit it with your desktop review. That's no longer the case.

[00:51:03.560] - Sue DeMarino

It's usually the data validation company that talks to you about the ISCA form, and you can download a copy of it from the Resource Center. If you have any more specific questions about the measures, you can always get in touch with me via email at xxxx@integralHS.Com, and I'd be happy to have a call with you or to schedule some time.

[00:51:33.350] - Lesley Malus Reed

I'll take the next three questions. Regarding props for the interview, what would you recommend if the review is 100 % virtual? What we recommend is having an agenda that has hyperlinks to all of those documents that they're requesting. And then during your interview, you can bring them up in the hyperlinks. So they will expect you to bring up those documents that the quality minutes that will show access metrics, for example, or that again, that business continuity plan. The next question is regarding review with all staff might be interviewed. How does this work when all staff is working remotely? They often will have a group interview. So for the front-line staff, you can give them the roster to choose from, or you can say, we've made these people available for that day. Who would you like to interview? And then they often will collect all the people. For the other interviews, it's up to you to choose who's going to be in that room. When we work with clients, we do a mock validation interview. You can see what the themes of the interviews are. That's our dry rehearsal where we go through the questions and the standards to see who's the appropriate person in the room and how that works out.

[00:52:49.500] - Lesley Malus Reed

And then the Distressed Caller for Virtual People, what you should have set up is an instant message to one of your peers to be able to let them know you have a Distressed Caller and you can instant message the information to them, just like you might when it's live, and then they can call 911 on your behalf while you stay on the line. Thank you for those questions. I'm going to hand it to you, Sue, for the corrective action section.

[00:53:14.360] - Sue DeMarino

Sure. Okay, so the last piece that I'm going to cover is what happens when you have a period of time where you are out of compliance with URAC standards. And my advice to you is corrective action, corrective action, corrective action. You need to implement it as early.

[00:53:33.460] - Lesley Malus Reed

As.

[00:53:34.010] - Sue DeMarino

It is discovered. You need to identify what you're going to do about the issue that you've identified, how you're going to come back into compliance. You're going to identify what the root cause was in order to be able to demonstrate compliance. I would tell you, I have seen organizations with three months of compliantof compliance with an issue that was out of compliance for even six months be able to demonstrate to URAC that they fixed the issue and it no longer is a problem. They typically will accept that corrective action plans as a way to mitigate issues. If it is absolutely going to be discovered by URAC, I would tell you to announce the corrective action plan in advance of your on site. They do not like surprises. It gives them an opportunity to look at your data pool and to identify when they should.

[00:54:37.010] - Thomas Goddard

Start.

[00:54:37.710] - Sue DeMarino

Looking for compliance. I believe there's one more question, Lesley. Can source verification of licensure be done by a bulk review with a licensure state, or does each license need to be verified individually?

[00:54:55.250] - Lesley Malus Reed

The personnel file must demonstrate that you completed primary source verification for that individual, and that verification included a review to ensure that it is active and without restrictions. So if you can pull it and demonstrate that it's primary source verified with that information, I can't see why not, but I've never seen that done historically. It's usually primary source verification for each individual.

[00:55:28.530] - Sue DeMarino

Okay. Any last comments, Tom?

[00:55:32.870] - Thomas Goddard

No, I'm just grateful that you all showed up, and we're delighted to have you here. If you have any questions for any of us that occur to you after this webinar, the follow-up email will give you a way to contact us. We'd love to chat with you on the phone about your accreditation needs.

[00:55:52.570] - Sue DeMarino

Great.

[00:55:53.430] - Lesley Malus Reed

Thanks, everybody, for attending.

[00:55:55.190] - Thomas Goddard

Thank you. Thank you. It's been great having you here.

[00:55:57.680] - Sue DeMarino

All right.