In my last post I lamented the deteriorating state of preparation for NCQA accreditation surveys. I also discussed the first of six steps for good survey preparation: understanding the specific requirements of the standard.
Identifying the required evidence of compliance can be challenging. Start off by reviewing the “Data source” section of the specific NCQA element. There are four data sources:
1. Documented process.
2. Materials.
3. Reports.
4. Records or files.
Definitions of each data source can be found in the glossary of the standards and guidelines.
But here’s the tricky part…the “Data source” section will list all the data sources applicable to the element but it won’t tell you which of the data sources are applicable to which factors and if you need all, some, or one of the data sources. Reading the “Explanation” section will provide some answers to these questions. Just don’t expect the answers to be crystal clear. [I understand that NCQA is working on this issue but it wasn’t corrected in the recently released 2010 standards.]
Let’s look at QI 7B: Access to Case Management. The element reads as follows:
The organization has multiple avenues for members to be considered for case management services, including:
1. Health information line referral, if applicable
2. DM program referral
3. Discharge planner referral
4. UM referral, if applicable
5. Member self-referral
6. Practitioner referral.
The data sources are listed as documented process, reports, and materials.
The explanation helps a bit. It says: “NCQA reviews the organization’s documented process and either materials or reports for evidence that the complex case management staff receives or has the ability to receive referrals from various sources [emphasis added].” From this you can safely assume that the documented process needs to describe how referrals to case management are accepted from each of the listed avenues.
If you read further, the explanation states: “The organization must demonstrate that it provides a means for member self-referral or practitioner referral by communicating the availability of programs and contact information (e.g., telephone numbers) to members and practitioners. The organization may communicate this information using printed materials or on its Web site.” This makes it clear that materials, as defined by NCQA, are the required data sources for factors 5 and 6.
With no other guidance in the explanation about which data sources apply to which factors, one is left to conclude that either reports or materials are acceptable data sources for factors 1-4. In preparing the evidence of compliance with this element, then, you would need to include a documented process (or processes) that address all six factors, materials for factors 5 and 6, and either materials or reports for factors 1 through 4.
Next time we’ll talk about step three: using support text to tell the story.
