Mastering NCQA Accreditation: Avoiding Top 10 Pitfalls for Survey Success
By Jana Altieri RN, MS, CPHQ - Healthcare Quality Consultant
January 7, 2024
With nearly 20 years in healthcare quality improvement, both in health plans and as a consultant, I bring valuable insights to enhance the NCQA accreditation process. This article highlights common mistakes organizations make, providing strategic tips to avoid pitfalls and optimize outcomes. Explore the top 10 errors to steer clear of for a successful NCQA accreditation survey.
1. Incomplete Data Sources:Make certain to furnish all necessary documented processes, reports, and materials. It's crucial to include at least one of each required Data Source when standards dictate multiple, following the specified look-back periods. For example, if the standard mentions "Documented Process and Reports," ensure you provide an example for both, not just one.
2. Streamlining Delegation Contracts:Avoid delays due to legal complexities in delegation agreements. Enhance efficiency by developing a concise table with checkboxes, outlining the responsibilities of each stakeholder. Communicate details, including the implementation date, via email to the delegate and seek their agreement with the proposed plan. Maintain an email trail to showcase "mutual agreement" for transparency in contracts and delegation agreements to provide as evidence should the signing of the agreement fall behind schedule.
3. Website Content Capture:Capture static website content during each look-back period. Simply directing the Surveyor to a link is insufficient; take screenshots at the start and end of each period to provide a tangible record and make sure the date of the screenshot and web address are shown.
4. Detailed Analysis:Go beyond tables, graphs, and charts in your reports. Ensure your results are accompanied by comprehensive narratives that include both quantitative and qualitative analyses. Utilize a checklist to meet specific analysis requirements for each standard (see Data Analysis for NCQA Guide as an example).
5. Entity-Level Reporting:Furnish data and evidence at the entity level, leaving no room for oversight. Ensure a meticulous analysis that includes specific lines of business or exchange states, each deserving its comprehensive report. Remember, it's a general rule of thumb that quantitative and qualitative analyses should beconducted at the entity level. Break it down first, and later it could be consolidated for reporting ifthat is permitted during your organization’s survey—it's more e ffective to dissect before aggregating. This approach guarantees a thorough and insightful examination, contributing to robust and accurate reporting. 6. Mastery of Standards:Allocate time to thoroughly grasp the standards; engage in repeated readings to ensure a comprehensive understanding. It goes beyond merely skimming through elements and factors—pay special attention to the Explanation and Examples section. Take advantage of the provided examples whenever feasible. Stay apprised of changes by securing annual updates of the standards, and actively educating business owners on any revisions. Distribute copies to all standard owners, facilitating easy reference and fostering a collective awareness of the evolving landscape. 7. Submission of Finalized Materials:Ensure that your submissions are not in draft form but are finalized materials. Standards necessitating the provision of actual emails, letters, or other materials distributed during the look-back period demand the presentation of the exact items submitted (e.g., not templates). In instances where materials are accessible on the website, you must notify members or providers of their availability. Guarantee that your submissions include appropriate date stamps to align with accreditation criteria. 8. Proactive Evidence Gathering:Commence the process of gathering and reviewing evidence well ahead of time. Delaying until the final month or two before submission leaves minimal room for adjustments. I've observed instances where organizations only recognize the omission of a report or policy from committee review when no more meetings are scheduled before the survey submission deadline. Initiating evidence collection several months beforehand provides the opportunity to address any oversights during the last committee meeting preceding your survey submission. 9. External Perspective on Processes and Documentation:Don't overlook the importance of seeking an external perspective on your processes and documentation. When deeply immersed in day-to-day business operations, it's easy to lose sight of the fact that outsiders may not fully comprehend certain systems or understand the reasoning behind established processes. Advocating for comprehensive documentation, from high-level policies to intricate Standard Operating Procedures (SOPs), is crucial. By thoroughly documenting every aspect, you ensure that another person can seamlessly step into the position without disruption should an unforeseen employee circumstance occur. This practice not only safeguards against uncertainties but also contributes to organizational resilience and knowledge continuity. 10. Comprehensive Meeting Documentation:Ensure that meeting minutes thoroughly capture the insights of practicing providers. Enlist someone knowledgeable about NCQA standards to perform final edits before approval. Incorporate titles and actual dialogue from practitioners while maintaining a balance between organization and conciseness. This approach guarantees that the minutes not only meet regulatory standards but also provide a clear and insightful record of practitioner input. By steering clear of these common pitfalls, you'll be well on your way to achieving a successful NCQA accreditation. For additional guidance and resources, feel free to reach out! #NCQA #Accreditation #HealthcareCcompliance #HealthcareQualitywww.managedcareconsulting.org 1/7/2024This serves as a general guide and is intended for informational purposes only. Users are strongly encouraged to refer directly to the official NCQA website at www.NCQA.org for the most up-to-date and accurate information.
1. Incomplete Data Sources:Make certain to furnish all necessary documented processes, reports, and materials. It's crucial to include at least one of each required Data Source when standards dictate multiple, following the specified look-back periods. For example, if the standard mentions "Documented Process and Reports," ensure you provide an example for both, not just one.
2. Streamlining Delegation Contracts:Avoid delays due to legal complexities in delegation agreements. Enhance efficiency by developing a concise table with checkboxes, outlining the responsibilities of each stakeholder. Communicate details, including the implementation date, via email to the delegate and seek their agreement with the proposed plan. Maintain an email trail to showcase "mutual agreement" for transparency in contracts and delegation agreements to provide as evidence should the signing of the agreement fall behind schedule.
3. Website Content Capture:Capture static website content during each look-back period. Simply directing the Surveyor to a link is insufficient; take screenshots at the start and end of each period to provide a tangible record and make sure the date of the screenshot and web address are shown.
4. Detailed Analysis:Go beyond tables, graphs, and charts in your reports. Ensure your results are accompanied by comprehensive narratives that include both quantitative and qualitative analyses. Utilize a checklist to meet specific analysis requirements for each standard (see Data Analysis for NCQA Guide as an example).
5. Entity-Level Reporting:Furnish data and evidence at the entity level, leaving no room for oversight. Ensure a meticulous analysis that includes specific lines of business or exchange states, each deserving its comprehensive report. Remember, it's a general rule of thumb that quantitative and qualitative analyses should beconducted at the entity level. Break it down first, and later it could be consolidated for reporting ifthat is permitted during your organization’s survey—it's more e ffective to dissect before aggregating. This approach guarantees a thorough and insightful examination, contributing to robust and accurate reporting. 6. Mastery of Standards:Allocate time to thoroughly grasp the standards; engage in repeated readings to ensure a comprehensive understanding. It goes beyond merely skimming through elements and factors—pay special attention to the Explanation and Examples section. Take advantage of the provided examples whenever feasible. Stay apprised of changes by securing annual updates of the standards, and actively educating business owners on any revisions. Distribute copies to all standard owners, facilitating easy reference and fostering a collective awareness of the evolving landscape. 7. Submission of Finalized Materials:Ensure that your submissions are not in draft form but are finalized materials. Standards necessitating the provision of actual emails, letters, or other materials distributed during the look-back period demand the presentation of the exact items submitted (e.g., not templates). In instances where materials are accessible on the website, you must notify members or providers of their availability. Guarantee that your submissions include appropriate date stamps to align with accreditation criteria. 8. Proactive Evidence Gathering:Commence the process of gathering and reviewing evidence well ahead of time. Delaying until the final month or two before submission leaves minimal room for adjustments. I've observed instances where organizations only recognize the omission of a report or policy from committee review when no more meetings are scheduled before the survey submission deadline. Initiating evidence collection several months beforehand provides the opportunity to address any oversights during the last committee meeting preceding your survey submission. 9. External Perspective on Processes and Documentation:Don't overlook the importance of seeking an external perspective on your processes and documentation. When deeply immersed in day-to-day business operations, it's easy to lose sight of the fact that outsiders may not fully comprehend certain systems or understand the reasoning behind established processes. Advocating for comprehensive documentation, from high-level policies to intricate Standard Operating Procedures (SOPs), is crucial. By thoroughly documenting every aspect, you ensure that another person can seamlessly step into the position without disruption should an unforeseen employee circumstance occur. This practice not only safeguards against uncertainties but also contributes to organizational resilience and knowledge continuity. 10. Comprehensive Meeting Documentation:Ensure that meeting minutes thoroughly capture the insights of practicing providers. Enlist someone knowledgeable about NCQA standards to perform final edits before approval. Incorporate titles and actual dialogue from practitioners while maintaining a balance between organization and conciseness. This approach guarantees that the minutes not only meet regulatory standards but also provide a clear and insightful record of practitioner input. By steering clear of these common pitfalls, you'll be well on your way to achieving a successful NCQA accreditation. For additional guidance and resources, feel free to reach out! #NCQA #Accreditation #HealthcareCcompliance #HealthcareQualitywww.managedcareconsulting.org 1/7/2024This serves as a general guide and is intended for informational purposes only. Users are strongly encouraged to refer directly to the official NCQA website at www.NCQA.org for the most up-to-date and accurate information.