Achieving and Maintaining Accreditation in Managed Care
Name:
Institution: Devry
Table of Contents
Introduction………………………………………………………………………………………3
Background……………………………………………………………………………………….3
Importance of accreditation…….………………………...………………………………………3
Accreditation Bodies……………………………………………………………………………...4
Literature review………………….…………………………………………………………….....4 Challenges that are experienced in achieving and maintaining accreditation…………………..…5
The role of the URAC as an Accreditation Body………………………………………………....5
How the URAC accredits healthcare institutions….........................................................................6
Quality assessment and control solutions in accreditation ……………………………………......8
Implementation of quality improvement and accreditation solutions…………………………......9 Justification…………………………………….…………………………………………………10 Summary and conclusion……………………….…...……………………………………………10 References ………………………………………………………………………………………..11
Achieving and Maintaining Accreditation in Managed Care
Managed healthcare organizations and professionals encounter numerous challenges on a yearly basis in the course of offering services, whereas the state, stakeholders, and clients (patients) expect to be reassured that bodies that render managed healthcare services are well equipped to meet their demands. Accreditation is, therefore, a detailed evaluation process through which an independent professional body or authority assesses another organization’s systems, structures, and procedures to certify that it satisfies the set industry criteria and standards (Bialek, Duffy & Moran, 2009). The evaluation and accreditation processes that are conducted by bodies such as URAC help in maintaining the quality of care in organizations. Physicians and nurses receive professional certification and training before they are allowed to legally provide services to the public. They are also issued with a practicing license as per the requirements of states in which they work. However, the medics require continuous training since their work is associated with new challenges that affect service delivery. Similarly, organizations that offer managed healthcare services need to continuously adjust their systems and structures in order to meet the changing demands and challenges in managed healthcare. Bodies that carry out assessment, accreditation, and compliance analysis include the National Committee for Quality Assurance (NCQA), American Standards National Institute for Personnel Certification Accreditation Program, among other organizations.
Background
Importance of Accreditation Accreditation ensures that quality improvement is attained in healthcare organizations. The process also assures recipients of care that institutions that serve them meet the criteria and standards for managed healthcare (Kongstvedt, 2013). Accreditation bodies assess the quality of aspects such as customer service, operations, and management that are essential in provision of healthcare services. The process is as well important to the government because it enables it to recognize and authorize managed healthcare providers that operate within the set parameters. The government also ensures that care providers are accredited in accordance with the Affordable Care Act. Since the rule was enacted to minimize the cost of medical services, managed healthcare is recognized as an important avenue for lowering expenditure in the sector.
Accreditation Bodies The federal government requires all managed healthcare agencies and organizations to be recognized by the Secretary of Health and Human Services (Gassiot, Searcy, & Giles, 2011). The main accrediting bodies for managed care organizations include the Utilization Review Accreditation Commission (URAC) and National Committee on Quality Assurance (NCQA) (Kongstvedt, 2013).
Literature Review According to Todd (2013), managed care accreditation is a procedure that often takes organizations a number of months or years to accomplish, but it enables them to attain, monitor, and maintain the care industry’s best practices in order to offer improved services to clients. Managed care organizations begin the accreditation process by examining their policies and procedures before providing a preliminary evidence report for evaluation by an external and independent body (Bialek, Duffy & Moran, 2009). The concerned accreditation body such as URAC then facilitates quality evaluation of the managed care organization by comparing its standards with those of other recognized players in the same industry. Standards of the organization are also measured and aligned to performance in order to meet the threshold that is set by the federal, state, and local authorities for healthcare service delivery.
Challenges that are Experienced in Achieving and Maintaining Accreditation in Managed Care Most care organizations experience numerous challenges in their quest to achieve and maintain accreditation standards. For instance, some attempt to manage their workforce and capacity systems in order to reduce the cost of services and make care affordable to clients. The challenges of attaining efficiency are widespread, especially with the introduction of new payment systems and legislation such as the Affordable Care Act (ACA) that are meant to reduce costs and streamline operations (Todd, 2013). Similarly, maintaining quality while guaranteeing availability of services in an era of industry changes is a major concern for managed care providers that intend to attain and sustain accreditation. While centralized systems make it easy for clients to pay for service charges, linking them to diagnosis processes, as well as private and employer-supported insurance firms is still difficult to attain for most managed care service organizations (Lighter, 2011). Furthermore, patients’ lack of adequate information on the standards of managed care organizations is a challenge that hinders attainment and maintenance of accreditation since different domains are often applied by accrediting bodies. The problem also makes it difficult for a single managed care institution or hospital that seeks accreditation to meet the minimum standards that are set by the national Health Ministry. Moreover, rapid changes in the healthcare sector require increased dynamism in organizations in addition to ensuring that provision of quality services is not compromised. Changes such as new insurance mechanisms reduced funding versus increased expenses, redistribution of human resources, and the rapidly evolving technology raise concern on the quality of services that healthcare organizations offer (Rickel & Wise, 2000). The Role of the URAC as an Accreditation Body URAC is one of the largest managed care accreditation bodies in the United States, and it borrows its domains from objectives of the department of Health and Human Services (Todd, 2013). Its main mission is to facilitate improvement in the quality and efficiency of healthcare organizations through processes of accreditation, measurement of quality standards, and provision of educational information. Some of URAC’s domains include disease prevention and treatment, communication and coordination, affordability and accessibility, operations management, as well as experience and engagement (Todd, 2013). Accreditation by URAC is always aligned to standards of federal health regulations and statutory requirements (Lighter, 2011).
How URAC Accredits Healthcare Institutions
Application
Healthcare organizations that intend to be accredited begin the process by filling application forms and providing essential supporting documents such as a preliminary evidence report. The documentation is supposed to be in accordance with guidelines that are provided by URAC. The process might take three to six months for completion, but the applicant has to pay a specific fee (Gassiot, Searcy, & Giles, 2011).
Documentation Review The accrediting agency (URAC) reviews all documents that are provided by the organization to ascertain whether it complies with the set standards (Todd, 2013). The documents include policies, organizational charts, program details, position descriptions, departmental plans on quality management, and contracts. URAC can, however, request for additional materials should there be need.
On-site Review URAC visits the managed care organization to verify compliance with standards and industry policies for it to achieve objective analysis of standards for assessment. The process involves conducting interviews with the healthcare organization’s management, auditing its quality control systems, as well as observing how staff members perform their duties. URAC also reviews the organization’s pre-existing programs (Rickel & Wise, 2000).
Committee Review The stage marks the final process of accreditation. A committee that is appointed by URAC conducts reviews of documentation and findings of the on-site report. Members of the committee often comprise experts and professionals from the healthcare industry. After examining the summarized reports, the committee delivers a determination and recommendation report on accreditation of the managed care organization.
Continuous Monitoring and Evaluation After accreditation has been issued, URAC embarks on a continuous education and organizational monitoring exercise to ensure that compliance to set standards and regulations is maintained. Failure by managed care organizations to adhere to the set quality standards might result into revocation of the accreditation certificate.
Fig 1: URAC Accreditation Process
[pic]
Quality Assessment and Control Solutions in Accreditation
Provision of Broader Quality Assessment Structures Managed healthcare organizations are expected to have already institutionalized internal processes of evaluating and measuring quality and reporting before URAC provides a broader and more comprehensive view of standards.
Conducting Regular Audits Apart from issuing authorization certificates and quality service recommendations, accreditation bodies such as URAC also carry out regular and continuous audits of managed care organizations. They monitor quality management, administration, as well as control systems to ensure that they still comply with the standards for which they were accredited.
Offering Education and Training Services Healthcare service delivery processes are associated with dynamic medical challenges that require an organization to adjust in order to remain relevant and provide quality care. Education and training ensures that employees are imparted with up-to-date skills and knowledge that enable them to deliver services in the most competent manner.
Benchmarking Quality Standards Achieving and maintaining accreditation in managed care imply that an organization has to keep up with quality standards of leaders in the same industry, as well as improve on its pre-existing levels. Accrediting bodies set benchmarks or quality service thresholds that can be used by managed care providers as comparative tools for instituting essential improvements.
Monitoring and Evaluation Besides federal processes of monitoring and evaluation of service delivery standards, accrediting bodies insist on the need for healthcare providers to voluntarily maintain the highest quality levels. However, the agencies have the mandate to sanction and withdraw accreditation certificates that were issued to managed care organizations that do not endeavor to maintain high standards of service delivery.
Establishing Professional Standards Besides evaluation of quality standards that are set by the accreditation bodies, the medical and healthcare industry is regulated with professional guidelines in the medical field. The accrediting bodies, therefore, consider professional input from experts in managed healthcare industry when developing standards.
Implementation of Quality Improvement and Accreditation Solutions Healthcare organizations are often issued with permits by governmental agencies before they commence operations (Gassiot, Searcy, & Giles, 2011). Some of the requirements that they have to meet include employment of staff with appropriate qualifications, as well as availability of standard infrastructural capacity such as buildings, water, and electricity. However, emerging laws and regulations place more emphasis on the quality of services than physical facilities. Even though an organization might implement quality improvement control measures and systems, it is also required to ensure that structural maintenance and design specifications are met. For instance, poorly installed fire exits and radiation protection systems may end up causing harm to patients. Moreover, the time frame for their maintenance depends on frequency of use and recommendations in evaluation reports (Bialek, Duffy, & Moran, 2009).
Justification
Accreditation is offered to an organization that can attain minimum standards that are set for quality service provision with the aim of stimulating or encouraging improvement of care. In contrast to accreditation that is based on an organization’s ability to justify its capacity to attain certain quality standards of service delivery, licensing demonstrates that the entity can maintain and protect basic health and safety requirements. Licensing can be carried out by a government entity, agent, or regulatory board. However, processes of quality assessment, accreditation, or licensing are geared towards better service delivery and continuous improvement.
Summary and Conclusion Achieving and maintaining accreditation is a complex procedure that is reliant on a variety of factors and conditions. Some of the factors include needs of the healthcare organization’s clients and the capacity of the firm to implement quality improvement measures in service delivery. Furthermore, the nature of healthcare challenges requires a pro-active approach that calls for professionals to update their knowledge and skills for them to keep up with emerging issues in the sector. Statutory laws and requirements such as insurance policies and the Health Ministry’s rules on quality service delivery also need to be amended continuously so that managed care organizations can improve their standards. The quality service delivery and accreditation mechanisms serve to enhance efficiency and productivity in organizations that seek to meet patients’ expectations.
References
Bialek, R. G., Duffy, G. L., & Moran, J. W. (2009). The public health quality improvement handbook. Milwaukee, Wis: ASQ Quality Press.
Gassiot, C. A., Searcy, V. L., & Giles, C. W. (2011). The medical staff services handbook: Fundamentals and beyond. Sudbury, Mass: Jones and Bartlett Publishers.
Kongstvedt, P. R. (2013). Essentials of managed health care. Burlington, MA: Jones and Bartlett Learning.
Lighter, D. E. (2011). Advanced performance improvement in health care: Principles and methods. Sudbury, Mass: Jones and Bartlett Publishers.
Rickel, A. U., & Wise, T. N. (2000). Understanding managed care: An introduction for health care professionals. Basel: Karger.
Todd, M. K. (2013). Physician integration & alignment: IPA, PHO, ACOs, and beyond. Boca Raton: Taylor & Francis.
----------------------- 1. Application to the URAC for Accreditation
4. Committee Review + Recommendation for Accreditation/ Declined Accreditation
