Tips from an Expert NCQA Accreditation Consultant

July 20, 2018

Professional Services Network, Inc.(PSN)  is pleased to present you with tips from a NCQA accreditation consultant. The information is intended to help those seeking accreditation to better understand the challenges that are often encountered within an organization and how to best navigate toward the goal of accreditation. 

We posed some specific questions to our consultants. Our first insight comes from Gloria Snidersich, MHA, RN, CPHQ, a long-time Quality Improvement expert, working alongside PSN, Inc. for many years to provide the guidance that health plans require to successfully achieve accreditation. You can read Gloria Snidersich's full bio below. 

 

Q. In your experience as an NCQA Accreditation consultant, what would you rank as the 3 most difficult/challenging aspects of accreditation that clients struggle with?

A. In my experience as a consultant and as a QI Director, the three most significant challenges of NCQA health plan accreditation or specialty accreditation/certification are these:

o   Gaining and maintaining “buy-in” that achieving and retaining NCQA accreditation or certification is a corporate-wide activity.  There is often a tendency for staff and/or management to think that the QI department is solely responsible for accreditation and that they are too busy with “real work” to learn, apply and document compliance with the NCQA standards.  So the challenge for the QI Director (or whoever is the lead on accreditation) is to help others understand the purpose of the standards and how compliance with the standards not only benefits the health plan member and the business, but is really the right process to follow.

o   Keeping up with changes in the standards and requirements for demonstrating compliance.  NCQA publishes health plan standards annually, which may include significant new expectations or also subtle changes, and it is important for the organization to remain current on all changes.  In addition, clarifications and revisions are often released several times during the year.  The organization is expected to adhere to those changes when published.  As a consultant, I can assist with keeping the organization up to date with changes.  But I see my role more importantly as mentoring the organization’s lead person on accreditation to grow in his/her own expertise in managing accreditation and ongoing compliance.  I often measure my success as a consultant by a decrease in the amount of assistance the organization needs in the day-to-day management of accreditation and getting to the point where they call upon me only for complex issues or concerns.

o   Continuity and coordination of care.  NCQA introduced standards a number of years ago aimed at improving the continuity and coordination of care across the continuum of care or during transitions of care, including between behavioral and medical care.  While this is an important aspect of care and service, given the variety of settings in which members receive care, I find these to be two of the more challenging of NCQA standards.  They require the health plan to analyze their specific data to identify areas in which potential opportunities for improved care exist, identify the barriers to better care, and develop interventions for improvement, and then to measure the effectiveness of those interventions.  Many health plans find these standards challenging, particularly because there is no one universal approach, but rather it obliges them to seek improvement activities specific to their plan.

 

Q. What advice would you give to clients seeking accreditation wanting to best prepare, prior to your arrival?

A.  I would say the most important preparation for using consulting services to assist with NCQA accreditation or certification efforts is to become familiar with the current NCQA standards, to have a lead person or project manager ultimately responsible for the accreditation/certification submission, and to recruit and/or assign key persons in each area of the organization to be responsible for the standards involving their area.  These preparations will set the stage for more effectively using the services of the consultant.

 

Q.  What should they be thinking of 12 months in advance… 6 months in advance… of their accreditation survey?

A. Depending on the accreditation or certification program and its readiness, an organization seeking NCQA accreditation for the first time should begin the process 2-3 years prior to the submission – the submission marks the beginning of the survey.  The organization first needs to obtain the applicable NCQA standards and perform a gap analysis to identify the key areas in which their organization may need to develop or refine processes in order to demonstrate compliance with the standards.  They may perform this gap analysis themselves, or may choose to use a consultant to assist with that process.  The organization needs to understand a few key aspects with regard to timing (preparing a timeline to the survey is very helpful):

o   If/when the organization identifies a future date by which they wish to (or are required to) achieve accreditation or certification, they need to plan on submitting an application to NCQA approximately one year prior to that date.  When the organization applies to NCQA for accreditation or certification, NCQA typically schedules the organization’s submission (the start of the survey) about nine months after the application.  Depending on the type of survey, completing the process from submission to awarding of status is usually 2-3 months.

o   Again, depending on the type of survey desired, the “look back period” varies.  While an Interim survey usually only requires that policies and procedures demonstrating compliance be in place prior to submission, an Initial or First survey usually requires that the policies and procedures be operational for at least six months prior to submission.  The organization needs to factor this into their timeline to be able to demonstrate compliance during the entire look-back period.  An Initial or First survey involves an onsite portion which includes reviews of actual files from the six month period prior to the survey, so the organization must be confident that compliant processes have been followed for at least that period of time and that those processes are well documented in the relevant files.  The organization should plan to perform a self-review of files or to have a consultant do a mock file review well in advance of the survey to ensure that compliance is met, and if issues are identified, that there is sufficient time to correct those processes to ensure compliance during the entire look-back period.

 

Q. What should companies do after accreditation to be in a better position for reaccreditation?

A. The organization needs to adopt a culture of continuous compliance.  A renewal survey may occur only every three years (two years for certification), but NCQA expects that the compliance with current standards is always in place.  Many standards require demonstrating that compliance for the 24 months prior to the renewal survey, while others require evidence of compliance all the way back to the previous survey.  As stated previously, while it is important that all areas of the organization accept responsibility for ongoing compliance, this is one area in which it is important to have a lead person or project manager who can keep staff informed of changes and periodically check for ongoing compliance.  As a health plan QI Director, in addition to ongoing compliance, I typically activated a “NCQA Readiness Team” about 18 months prior to the renewal survey.  I would meet with small groups of staff over the next month or two to go through their relevant standards one by one, to ensure that they have implemented any changes, are keeping up to date with requirements such as annual reports and analyses, and to establish due dates for submission of needed materials for the upcoming survey.  I found that process to be successful in all of the surveys in which I served as the lead.

 

Q. Where is the future of accreditation headed?

A. NCQA has always been forward-thinking in its field and I expect that trend to continue.  As venues and technology for the provision of health care evolve, NCQA has kept pace with developing standards related to innovations and for each setting, such as providing online services for members, Patient Centered Medical Homes (PCMH) or Accountable Care Organizations (ACO).  While process standards are important, NCQA places equal weight on outcomes.  In the area of health plan accreditation, outcomes, as measured by HEDIS®, account for 50% of the accreditation score, with compliance with the standards accounting for the remaining 50%.  In addition, while the formal survey takes place every three years, the health plan must demonstrate performance through HEDIS annually, which may result in a change in the health plan’s accreditation level.  The PPACA of several years ago required that health plans be accredited by a recognized accrediting agency prior to being offered on the Exchange, which is leading to more health plans considering accreditation than ever before for business purposes.  In addition the OPM is moving toward requiring accreditation for health plans serving government workers.  I feel that accreditation and/or certification will continue and increase in importance to the viability of the health care organization and will factor into the purchaser’s decision, whether it’s an employer or a private purchaser.

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If you'd like to speak directly with Gloria Snidersich or another one of our qualifed NCQA accreditation consultants, please contact Marlene Buczynski at [email protected]. You can also visit our website at https://www.psninc.net/consulting/.


Gloria Snidersich, MHA, RN, CPHQ, is a health care professional with a strong clinical background and extensive experience in management and supervision, quality improvement, and program development.  As a consultant, Gloria has worked with health plans seeking NCQA Health Plan (HP) and Managed Behavioral Health Organization (MBHO) accreditation, as well as organizations seeking NCQA certification in credentialing.