While the support text is key to help the surveyors understand HOW you comply with a requirement, it’s the evidence of compliance itself that will get you actual credit for meeting the standard.
Once you’re clear on what data sources are required you are in a position to select the evidence and to determine the right amount of evidence.
This is one area where more is definitely not better. To do this right you really need to understand what the standard is about. If you do not you will not be able to reliably supply the correct evidence of compliance or the correct amount of evidence.
For most standards you need to show that you have been in compliance with the requirements throughout the look-back period. For renewal surveys this typically means two year’s worth of evidence.
Let’s look at UM 10B as an example of how to proceed.
This element addresses a health plan’s written process for technology evaluation. The data source is “Documented Process” and the look-back period for renewal surveys is two years. The most common documented process used as evidence for this element is a policy and procedure, or set of related and well-integrated policies and procedures, on technology evaluation. Any evidence other than a documented process will just be noise for the surveyors. Reports and materials are meaningless for scoring this element.
How many documented processes do you need to attach?
However many documented processes cover the look-back period. For an organization undergoing a renewal survey that has not changed its technology assessment P&P in the two years prior to the survey date, only one P&P will be needed.
One of the most frustrating experiences a surveyor can have is for an organization to load up the ISS with every document that might be relevant to an element. I once received 100 documents for Continuity and Coordination between Medical and Behavioral Healthcare!!! I’ve had similar experiences with other standards and other organizations. And I can assure you that I am not alone among surveyors.
The right amount of evidence is critically important. The Standards and Guidelines describe scope and meaning of the standard (the explanation), what evidence is required (the data source), and the amount of evidence (the look back period). What you need to do is determine precisely what, and how much, evidence is needed to demonstrate that your organization is in compliance with the standard.
If you don’t do that, you are likely to get lots of questions from the surveyors.
