a.   Do progress notes make reference to a new medication? Do the progress notes have evidence that the patient was asked about medications?  Make sure the referenced medication is listed on the medication list! The patient record summary should be continuously updated as orders are received and carried out.  At least monthly, review medical records comparing medications to those listed on the medication profiles.  Take a look at NPSG.03.06.01 Note 3, for the definition of “good faith” effort.  Documentation of supporting assessments with each visit, along with a monthly review, is evidence of a “good faith” effort!

B   Lack of evidence of drug regimen review can be a potential hazard in the Joint Commission accreditation process, as can lack of evidence of physician notification in the event of drug interactions. Drug regimen reviews performed by a licensed professional who can take an order, such as a nurse, physical therapist or occupational therapist, should occur at start of care, recertification  and when there are changes in the medications ordered.  Anytime there is a note in the record regarding a drug interaction there should also be a note or recording of successful attempts to contact the patient’s primary physician, or an agent of the primary physician, such as an office nurse.

c.   Patient education is also important in accreditation Does your facility’s documentation support the patient being educated about their medication, and, if so, what type of education was given? Information should include what to watch for, in regards to side effects, as well as any possible drug interactions.

d.    If a new medication is an antibiotic, is the antibiotic review included in the agency’s Infection Control program? Daily clinical notes should be reviewed, and when there is an antibiotic listed, an infection screen form must be completed so that the antibiotic is captured in the Infection Control program.

e.    Did you know that National Patient Safety Goal 8 has now been changed to Standard 3.06.01s? What does your agency need to do to work toward meeting the national goal for Patient Safety?

f.    During the monthly review of medication regimen, inquire if the patient is taking medications as ordered. The nurse can also assess if the patient discontinued the medication. For instance, if the medication is dated 1/1/2011 and today is 2/1/2011 (medication ordered for daily use), is there  half a bottle of medication remaining?   Findings such as insulin non adherence, or discontinuing potassium when taking a diuretic, would be some examples of problem areas.

Daily review of  progress notes can lead to identification, prevention and/or corrections of medication – related administration issues , and prevention and / or correction of  problems as they occur.   Keep a list of those patients whose medication administration is the reason for a home health visit, and include several of these patients in the comprehensive chart review.  Hold staff accountable.

A free resource for drug interactions with severity levels: http://www.drugs.com/drug_interactions.html.  The site offers teaching guides too, and it is free.

Frequently our consultants are asked by our clients to help with choosing which accreditation will be the most appropriate for their particular business.  Some important considerations include: their client preferences or mandates, value of performance measurement data required by a particular accreditation process, cost, contribution to company infrastructure or marketing advantages.

Positioning one’s company in this current healthcare reform environment is challenging.  It is important  to examine your goals  to calculate the most  advantageous accreditation path: TJC, CHAP, NCQA, URAC?  We know them all, and can sort through the maze with you.

Call or write Peggy Thomas, Senior Consultant today to discuss your accreditation needs!

At PSN, we provide expert NCQA accreditation preparation in the following areas:

• Health Plan (HP) Accreditation
• Managed Behavioral Healthcare Organization (MBHO) Accreditation
• Preferred Provider Organization (PPO) Accreditation
• Disease Management (DM) Accreditation/Certification
• New Health Plan (NHP) Accreditation
• Medicare Deeming (MA)
• Special Needs Plans (SNP)
• Credentials Verification Organization (CVO) Certification
• Physician Practice Connections (PPC)
• PPC-Patient Centered Medical Home (PCMH)
• Physician/Hospital Quality (PHQ)
• Utilization Management (UM) and Credentialing (CR)
• Privacy Certification for Business Associates
• Wellness and Health Promotion (WHP)
• Physician Recognition Programs in Back Pain (BPRP), Diabetes (DPRP) and Heart/Stroke (HSRP)

Our NCQA consulting services for these programs include:

• Assessment of documentation compliance to NCQA standards
• Expert blueprint for compliance
• Gap analysis
• Assembling of your application
• Policy and procedure development
• On-site mock surveys
• File audits
• Program design
• And more

When you work with PSN, you will be successful! To learn more, view our NCQA Accreditation page or contact us.

1.    Provide adequate resources: The NCQA standards not only address quality improvement, but they also address a number of other areas, too.  Areas such as utilization management, provider relations, marketing, informatics, member services and support must be involved.  These areas must be supported by senior management and must be afforded the training and time to devote to the survey preparation effort.

2.   You can never start too early: Many NCQA standards require an organization to demonstrate compliance over a number of years.  It is advisable for an organization to start preparation activities three years prior to a survey.  This will afford the organization with time to make sure that structure and processes are in place and that required measurements and improvements can be documented.

3.    Engage expert help: Preparation for an NCQA survey requires expertise in NCQA subject matter and complex project management skills.  Often times the day-to-day working operations within an organization are all encompassing and do not afford individuals with the time to devote to the NCQA process.  If permanent staff devoted to NCQA oversight and preparation is not possible, consider investing in a consultant.   A consultant can establish project plans, interpret the intent of the standards, assess compliance, participate in and coordinate preparation activities, and track time lines and milestones.  If considering the use a consultant, make sure that the consultant is an NCQA surveyor.  Only an NCQA surveyor will truly understand the NCQA process, the intent of the standards, the philosophy behind NCQA accreditation and certification.

Ellen is a health care executive with more than 25 years of diversified experience in developing, training, implementing, supporting, and promoting health services strategies.  She has been an active NCQA surveyor since 1991 and helped to develop many of the NCQA Accreditation and Certification products.  Through her hands-on and personable consulting approach, Ellen has successfully guided many organizations towards successful NCQA Health Plan Accreditation and NCQA Disease Management Accreditation and Certification.

HEDIS measures are associated with many important health issues. Data collection includes collecting information about varied  aspects of care provided to individual health plan members by health plan participating physicians. Annually, information is collected through the review of randomly selected medical records located in physician offices or other health care settings to identify evidence of the following:

• Cervical Cancer Screening, Women Age 21-64: PAP test performed within 2010 or prior 2 years.
• Breast Cancer Screening, Women 40 – 69: Mammogram completed  in 2010 or 2009.
• Childhood Immunizations completed by 2nd birthday: immunizations administered include DTaP/DT, IPV, MMR, HIB, hepatitis B, hepatitis A, and VZV.
• Colorectal Cancer Screening, adults 50 – 75 years old:  Occult blood testing conducted annually or sigmoidoscopy in 5 years or colonoscopy in 10 years
• Comprehensive diabetes care, Age 18-75:  Yearly screening of HbA1c testing,  LDL-C, Retinal eye exam, nephropathy screening test,  Blood pressure measurement
• Controlling High Blood Pressure, ages 18-85: if diagnosis of hypertension is present, is blood pressure controlled, i.e. < 140/90.
• Prenatal and Postpartum Care, pregnant women: Prenatal visit occurred within first trimester; postpartum visit between 21 and 56 days after delivery
• Beta-blocker treatment after heart attack, Age 18 and older: for patients who were hospitalized and discharged after an acute myocardial infarction, medication prescribed included treatment  with beta-blockers for six months after discharge

Many health plans evaluate and utilize HEDIS data to enhance the quality of the health care services that they provide. HEDIS data allows employers, as well as benefit consultants, to select the best plans suited for their employees needs. NCQA makes sure that the HEDIS results are valid through a health plan audit process that checks the accuracy of  the HEDIS measures that are collected and also evaluates how the data is  measured.

HEDIS measures are essentially a report card that evaluates the health plan’s success in providing preventative care delivered by physicians in a health plan’s network of providers.

References:
Fallon Community Healthplan (2010) 2011 HEDIS® measures. Retrieved 1/22/2011 at
http://www.fchp.org/providers/resources/hedis-measures.aspx

National Committee for Quality Assurance  (2011) 2009 HEDIS Performance Measures. Retrieved 1/22/2011 at
http://www.ncqa.org/tabid/855/Default.aspx

In the United States and internationally, recognized organizations providing a review process for organizations seeking voluntary accreditation include:

• The Joint Commission on Accreditation of Healthcare Organizations (TJC)
• Healthcare Facilities Accreditation Program (HFAP)
• National Committee for Quality Assurance (NCQA)
• Utilization Review Accreditation Commission (URAC)
• Accreditation Commission for Health Care (ACHC)
• Healthcare Quality Association on Accreditation (HQAA)
• Accreditation Association for Ambulatory Health Care (AAAHC)
• Community Health Accreditation Program (CHAP)
• Commission on Accreditation of Rehabilitation Facilities (CARF)

The process of healthcare accreditation usually involves a review of infrastructure, i.e. policies and procedures, job descriptions, credentialing processes, information management, as well as an operational assessment to determine that written documents stating policy and procedure are carried out in accordance to what an organization says it does. An assessment of organizational structure, processes and outcomes affecting the delivery of client healthcare services are carefully assessed in order to determine quality practices are in effect as that organization provides consumer services.

To meet accreditation standards, organizations invest resources of people and time because of a desire to be among the best, which meeting national standards exemplifies. Today, cost containment can affect quality and quantity of services, and an organization that meets accreditation standards is one that a consumer can have additional confidence in as standards of national quality and service have been achieved.

Reference:

Agarwal, R. (2010). A Guideline for Quality Accreditation in Hospitals. Quality Digest. Retrieved
1/15/2011 at http://www.qualitydigest.com/inside/health-care-article/guideline-quality-
accreditation-hospitals.html

1. Provide adequate resources: The NCQA standards not only address quality improvement, but they also address a number of other areas, too. Areas such as utilization management, provider relations, marketing, informatics, member services and support must be involved. These areas must be supported by senior management and must be given the training and time to devote to the survey preparation effort.
2. You can never start too early: Many NCQA standards require an organization to demonstrate compliance over a number of years. It is advisable for an organization to start preparation activities three years prior to a survey. This will afford the organization with time to make sure that structure and processes are in place and that required measurements and improvements can be documented.
3. Engage expert help: Preparation for an NCQA survey requires expertise in NCQA subject matter and complex project management skills. Often times the day-to-day working operations within an organization are all encompassing and do not afford individuals with the time to devote to the NCQA process. If permanent staff devoted to NCQA oversight and preparation is not possible, consider investing in a NCQA consultant. A NCQA consultant can establish project plans, interpret the intent of the standards, assess compliance, participate in and coordinate preparation activities, and track time lines and milestones. If considering the use of a NCQA consultant, make sure that the consultant is an NCQA surveyor. Only an NCQA surveyor will truly understand the NCQA process, the intent of the standards, the philosophy behind NCQA accreditation and certification.

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Written by: Ellen Pauley, RN, MSB. Ellen, one of PSN’s NCQA consultants, has been an active NCQA surveyor since 1991 and helped to develop many of the NCQA Accreditation and Certification products.

PSN is an industry-leader in NCQA accreditation services.  Each of PSN’s NCQA consultants have worked as NCQA surveyors, have over 30 years of combined NCQA surveyor experience, and total more than 50 years of NCQA consulting experience.  Feel free to contact us to learn more about our NCQA accreditation services.

As a helpful resource, PSN helps you sort through the application documents, supported documentation, and the plethora of instructions that need to be followed to ensure a successful submission of your URAC application. Here are some helpful hints that may make the transition a little easier for you and your organization.

1. Once you receive your username and password from URAC, watch the tutorial and read the instruction manual thoroughly to familiarize yourself with the process.
2. Be aware that documentation will be needed to support both standards and substandards. In some cases only a portion of a document will apply.
3. As you familiarize yourself with each standard, look at your policies and procedures and keep a record of which documents (or portions of documents) support which standard/substandard by writing down which section of text supports which part of the standard or by electronically highlighting and labeling each section.
4. A helpful hint for highlighting documents… Using the “Comment” feature on Microsoft Word can make your job a lot easier. First, make sure you are in “Print Layout” mode. You won’t see the commenting if you’re in “Normal” mode. Then, just select the portion of text that supports the standard, go to the Insert menu (Word 2003) and click on “Comment.” A comment bubble will appear, and you simply type in the name of the standard/substandard it refers to. If you have a sentence in the middle of an already highlighted portion that applies to a different standard, create a new comment. When you select that comment, it will highlight just the portion that applies to the other standard.
5. Wise idea: Do not start loading documents onto AccreditNet until they are absolutely final. At this time, if a document needs to be replaced, it must be removed from each standard it supports before it can be deleted from the library. Then, when the edited document gets uploaded, it needs to be reattached to each standard. This can be time-consuming.
6. AccreditNet only allows nine (9) support documents to support each standard (including the substandards). Sometimes, more than nine documents are necessary to support a standard. For example, you might have 20 documents that support a standard which has four substandards.

a.    To submit all 20 documents, the best way is to create four folders, identifying each by standard/substandard number/letter (e.g., 3a), and copy supporting files into each folder. Make sure that citations are highlighted within each document file of each folder.
b.    When uploading each zip file, enter a name such as “Support Documents for Core Standard 3c” in the Document Title box. You can have as many documents in each zip file as are needed to support the standard, because it will only register as four (in this case) zip file documents.

These are only a few ways to help expedite the process, but if you have additional questions, URAC is very helpful. They can be reached at (202) 216-9010 or accreditnet@urac.org.

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Professional Services Network is an industry-leader in URAC Accreditation services. All of our URAC consultants have worked as URAC surveyors and have many years of URAC consulting experience. Feel free to contact us or learn more about our URAC Accreditation services.