NCQA Accreditation: Failure vs. Success

July 16, 2015
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For quite some time now the Accreditation clock has been ticking.  With rapidly changing healthcare requirements, modified regulations, and sweeping reform, organizations have been racing, stumbling, and hurtling themselves toward successful NCQA health plan accreditation.  Some groups have risen to the occasion with a smooth transition from interim to full accreditation status…..and some have stumbled, including a few large national insurers.

For quite some time now the Accreditation clock has been ticking.  With rapidly changing healthcare requirements, modified regulations, and sweeping reform, organizations have been racing, stumbling, and hurtling themselves toward successful NCQA health plan accreditation.  Some groups have risen to the occasion with a smooth transition from interim to full accreditation status…..and some have stumbled, including a few large national insurers.

No matter what size the organization, there are a few key distinguishing factors that delineate successful organizations from those who struggle.  Today we are going to talk a bit about NCQA Health Plan Accreditation, how firms can define success (besides their accreditation status) and the four key factors that make a difference in accreditation success…regardless of the size or sophistication of the organization.  Let’s dive in!

1. Eliminate the Mind Set of Accreditation Having a Finish Line

Almost every organization knows that the heavy lifting when it comes to accreditation happens months, if not years, before the assigned onsite survey.  Timelines are established, requirements are gathered, policies, procedures, and work flows are developed, and that does not even begin to touch on clinical measurements and reporting.  Taking an organization from a non accredited status, to full accreditation involves complex work that touches on nearly every member of the organization and the way that countless daily tasks are performed. This is one of the reasons why a successful accreditation is a mark of distinction.  But organizations often tend to think of accreditation as something separate from their daily tasks, and not part of ongoing operations.  The truth is, for successful organizations there is no finish line for accreditation because it becomes part of the organizational culture.  When staff across all levels embrace accreditation required activities as quality and organizationally required activities, these processes and protocols become woven into the natural operations of an organization. They are not something separate done for the sake of becoming accredited, they are something that is committed to as a way of providing superior care and adhering to the strictest standards of quality.

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2. Don’t Start Preparing Soon, Start Preparing Now…..Even if You are Already Accredited

When working with clients, one of the things we most commonly encounter is an organization whose staff and resources are taxed due to failing to begin preparing for accreditation early enough.  For first time NCQA Health Plan Accreditation, lead time to get your organization ready for the full accreditation process should begin about three years before you would like to be accredited.  For those with interim accreditation, preparation for your next re-accreditation should begin the moment the surveyor walks out the door.

“Accreditation readiness should be a constant and ongoing part of an organization’s operational priorities” states Gwen Roberts, SVP of the Consulting Division at BHM “large organizations have a tendency to go through the accreditation process, then forget to keep up with the requirements in between reviews which causes extra frustration for employees, and loss of productivity and increase in costs for the company.”

Regulatory requirements as well as accreditation standards are often changing, make sure that you are constantly staying up to date with what will be required for the next accreditation and delegate an accreditation sub committee to actively track these items and required tasks on an ongoing basis. Don’t wait until the last moment, or you may find that it is too late.

3. Understand that Accreditation Is Not Just a Job For the Quality Department

As mentioned before, the process of becoming accredited, and remaining ready for the next accreditation touches nearly every member and department within and organization. Some of the functional requirement areas include:

  • Utilization Management
  • Credentialing and Re-credentialing
  • Member Rights and Responsibilities
  • Consumer Assessment
  • HEDIS (Health Plan Employer Data Information Sets)
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Leadership needs to actively understand that successfully accreditation is not a job for the Quality or Compliance Department alone.  Those organizations who are most successful at obtaining the highest levels of accreditation, and being actively prepared for re-accreditation are those that have strong cross functional teams working on accreditation, or have provided appropriate authority for their Quality Department which is supported by leadership to facilitate collaboration throughout.  For ultimate success an Accreditation Committee which is ongoing is established and consists of a representative member from each Department impacted is instituted to spearhead efforts and stay on top of requirements as they change.

4. Don’t Underestimate the Value of Outside Resources

Well, here is typically the place where a firm would plug the value of you hiring them for NCQA Health Plan Accreditation Assistance, and while there are dozens of ways in which BHM Healthcare Solutions, Inc. saves clients time and money, and a slew of positive industry recognition our firm has garnered, there is an additional outside resource that Health Plans often overlook when seeking accreditation….the accrediting body itself, in this case NCQA.

It is in the interest of the accrediting body that your health plan be successful, and NCQA has assembled an entire toolbox of seminars, publications, online guides, and resources to support you in your mission.

Of these resources, the Quality Profiles are the most beneficial (and also extremely transparent).  Quality Profiles are the NCQA Publication of best practices that show what obstacles other organizations faced, how they effectively dealt with them, and what proved successful.  Of course there is no better teacher than experience, so take advantage of the resources provided, hire the help that you need, and remember that Health Plan Accreditation not only makes your organization better, but improves the quality and effectiveness of care for those who are served.