Approved: Accreditation makes CM programs more marketable
Here’s how to turn a $10,000 gamble into a sure thing
The final draft of the new accreditation standards for case management programs from the Washington, DC-based American Accredi ta tion HealthCare Commission/URAC became available in June. As of late October, seven case management programs nationwide already had earned Commission/URAC accreditation, and many others had requested applications or had applications in the review process.
The "why" is simple: Accreditation gives case management organizations a nationally recognized quality seal of approval. The "how" turns out to be simple as well, at least for the well-prepared, according to professionals who have been down the Commission/URAC accreditation road before.
"The first step is to get the application and break it down into ele mental parts. If there are 32 standards, set up 32 folders," says Stevin R. Nelson, CLU, FLMI, PAHM, business analyst/quality assurance coordinator with All American Financial in Worcester, MA. Nelson has received Commission/URAC accreditation for the company’s utilization management program and is applying for accreditation of the company’s case management program. "Once you’ve done that, prioritize the standards. Take the standards you know you are farthest from satisfying and tackle them first."
"When we first received a copy of the standards, we sent them out to each of our nurses to read and then had meetings — often by teleconference — to bring up standards that concerned us," says Nancy Schmitt, MEd, RN, CCM, coach for the nurse case managers at All American Financial. "We do workers’ comp and personal injury protection case management. We had some questions about how the Commission/URAC interpreted certain standards and how they applied to us."
For example, state laws govern how workers’ compensation case managers gain access to medical records. "One of the Commission/URAC standards requires case managers to gain consent to do case management. We wanted to clarify how that should be handled when the insured is not the claimant but rather the employer," says Schmitt.
Luckily, the accreditation application comes with a standards manual that includes instructions for completing the application and an int erpretive guide for each standard. "It’s very important not only to review the standards but to review the interpretive guide several times. I used this book constantly as I was working on individual standards to focus on the intent of the standard and what to submit to prove the standard had been met," says Ginny Werner, RN, CCM, director of medical management in the Atlanta office of PractiCare, based in Winsor, CT. Recently, she successfully completed the accreditation process for utilization management programs and is watching the progress of the new case management program accreditation with great interest.
"In the case of the consent issue, our nurses were very concerned. However, if you look at the standards manual, it’s clear that what the Commission/URAC is looking for is to involve the claimant. You have to involve the claimant to do true case management," notes Nelson.
Werner adds that the Commission/URAC is "user-friendly."
"Every organization that goes through the accreditation process is assigned an accreditation reviewer to help answer questions about the application and the standards." she notes. "The Commission/URAC encourages organizations to call them with questions. The reviewers are very helpful, and asking questions doesn’t jeopardize your application."
However, she cautions that you should still organize your thoughts before you pick up the phone. "Your head is at times full of questions. I tackled what I felt were the obvious standards on my own and then line-listed questions about areas that were not clear to me. I only asked questions about issues where I really didn’t understand the intent of the standard. In the end, I called three times before submitting my document.
I’m in charge here’
"As you work through the entire process, you have to be extremely organized within your own mind and work flow to keep the process from being an overwhelming one. It takes a very detailed person to do this. It may be in some organizations more than one person works alone on the accreditation application process, but there has to be an appointed person to take the lead in pulling all the required elements together," Werner says.
Nelson agrees. "Even though at times the process requires a team approach, you have to have one person to drive the process forward," he says. "Even the Commission/URAC recommends having one seriously accountable person as the lead."
However, Werner and Nelson agree that even a "seriously accountable" individual needs input from other departments to complete an accreditation application. "No matter how well you think you know your business, you benefit from others’ input," says Nelson. "You must hold teamwork meetings to address specific standards and to write, or revise, the policies and procedures that the Commission/URAC requires be documented."
The standards must be addressed with other departments that interact with the program seeking accreditation as well, notes Werner. "Data collection, faxing, confidentiality, interfacing between departments — all of these things are addressed in the standards. Every single person in our organization was touched somehow by the Commission/URAC requirements, and they had to be in the loop."
Werner held several meetings to keep the entire organization informed about the accreditation process. "We’re a small organization. A larger organization might want to only include key executives of each department in its meeting. We included everyone."
The first meeting was meant simply to explain the accreditation process to PractiCare employees. "I explained the process from the application, the desktop review phase, the on-site visit, the two committee-level reviews. I gave each department a clear idea of what expectations I had for it and a time frame for completing required tasks," says Werner, adding that she suggests organizations with strong programs already in place allow a minimum of 90 days to complete an accreditation application. "Newer programs that will have to work harder to meet the standards need at least six months."
The next set of interdepartmental meetings focused on individual standards. "We needed to list what we already had in place, what we needed to develop, and how we could document each standard," says Werner. "We drilled down what needed to be enhanced and who would be responsible for working on each standard. Most of this activity took place with the medical management staff. For members of the medical management team, the Commission/URAC application became a regular agenda item at the top of every staff meeting."
$10,000 gamble
Many organizations find that the accreditation process has some hidden benefits.
"Everyone recognizes the marketing value of accreditation, but there are other benefits, as well," notes Nelson. "The accreditation process requires you to formalize and document many policies and procedures that are already in place and develop others that improve the overall quality of your program."
Those policies and procedures make it easier to evaluate employees’ work and support them in decision making. "Before we completed the utilization management accreditation process and came out with a new and improved policies and procedures manual, we might have audited an employee’s work and had the feeling that they had missed a vital step without being able to document it. Now, we have a policies and procedures manual that clearly defines each step in the process, and we have clear guidelines for evaluating our employee’s work product."
The standards also enhance an organization’s corporate culture, says Nelson. "If you are in a room and people are presenting their opinions, sometimes the argument, That’s what the URAC standards say,’ gives everyone a structure to buy into. Before, we had accreditation processes for individual case managers. You could be the best case manager possible, but if your organization didn’t support you, you were lost. Now, case management programs are being held to the same degree of accountability as individual case managers."
Stay accredited
The Commission/URAC standards also support things like continuing education for case managers, says Schmitt. "It requires the company to make sure its case managers are credible, educated, updated individuals. This company has always supported its case managers. Applying for accreditation of our case management program simply formalizes that support. It’s very validating for our case managers."
Werner agrees. "The standards require you to formalize and document hiring practices, advancement practices. The standards are very detailed about orientation and training programs. The tools you develop to satisfy the accreditation reviewers will make your job easier in the future. You’re going to use the tools you develop."
However, even though accreditation has many benefits, it’s not a process to be entered lightly, cautions Werner. "The applications for accreditation can be as much as $10,000 and must be renewed every two years. Although no one mandates that you be accredited, once you are, you are really obligated to keep it up," she notes. "It’s an ongoing process once you commit to it. It’s public knowledge if you apply for accreditation and don’t receive it. It’s also public knowledge if you obtain accreditation and don’t keep it up. Even though your decision not to renew your accreditation may be a financial decision, the public will perceive it as a quality issue. The public will most likely assume that you lost your accreditation and that your standards are no longer as high. Once you enter the process, your credibility is at stake. Don’t start this if you don’t plan to carry it through," she says.
Finally, Werner and Nelson urge case management programs applying for accreditation to treat "shoulds" like "shalls." The standards are written so that "shoulds" are recommendations for best practice and "shalls" are required elements, explains Guy D’Andria, vice president of policy for the Commission/URAC. For example, the current standards state that accredited case management programs "should" hire case managers who meet one of the following standards:
• have a bachelor’s degree in a health care field and licensure as a health care professional;
• hold one of several nationally recognized case management certifications;
• have licensure as an RN with a specified number of years of clinical experience.
"An earlier draft of the standards had those shoulds’ as shalls’ and, traditionally, our shoulds’ do move up to shalls’ at a later date," notes D’Andria.
"I have always read a should’ as a shall.’ It gives me a step up when it’s time for reaccreditation," says Nelson.
Don’t make a distinction between "shoulds" and "shalls," agrees Werner. "It will not only save you time during the reaccreditation process, it will help you attain an even higher level of quality.
"Although the process is tedious, it’s also an excellent method for achieving a gold standard of care and educating yourself along the way. There is a wonderful sense of accomplishment and pride through the entire organization when the accreditation process is successfully accomplished. [In most cases, organizations] don’t need Commis sion/URAC accreditation, but it’s a nationally recognized gold standard that enhances your program internally and externally." (For more information on case management program accred itation, see Case Management Advisor, December 1998, pp. 197-199.)
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content