Surviving an NCQA Survey

Surviving an NCQA Survey

Life preserver 2

The NCQA standards are very demanding and purposely set high to encourage health plans to continuously enhance their quality. Preparation and teamwork will be your life preserver in the stormy sea of a survey.

By Kristi Thomason, RRA, MPA

THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) survey is a nationally recognized evaluation that purchasers, regulators and consumers can use to assess managed care plans. NCQA accreditation evaluates how well a health plan managed all parts of its delivery system, physicians, hospitals, other providers and administrative services, to continuously improve health care for its members. The goals of NCQA are to foster the development and strengthening of internal systems for quality improvement, assess the quality of medical management and develop reliable performance measures.

NCQA reviews are rigorous on-site and off-site evaluations conducted by a team of physicians and managed care experts. A national oversight committee of physicians analyzes the team’s findings and assigns an accreditation level based on the plan’s performance against the NCQA standards.

The NCQA standards, developed by employers and health plans, are very demanding and purposely set high to encourage health plans to continuously enhance their quality.

Categories for Accreditation

NCQA accreditation is based on a review of more than 50 standards in six categories of health care management. They include Quality Improvement, Physician Credentials, Members’ Rights and Responsibilities, Preven-tive Health Services, Utilization Management, and Medical Records.

NCQA has developed a weighted scoring system to assist making accreditation decisions. Currently, quality improvement is weighted at 40 percent, credentialing at 20 percent, utilization management at 10 percent, members’ rights and responsibilities at 10 percent, preventive health services at 15 percent and medical records at 5 percent.

As of Oct. 31, 1997, more than half of the nation’s 630 health maintenance organizations (HMOs) were involved in NCQA’s accreditation program. Collectively, these health plans cover more than 75 percent of all HMO enrollees. Reasons for Accreditation

Plans seek NCQA accreditation for a variety of reasons. Frequently they are seeking a competitive edge in their local market–many want to prove to their boards of directors, members and purchasers that their quality improvement systems work well. Some plans are mandated to seek external review, either by their state, corporate offices or major purchasers.

There are many benefits to participating in the NCQA accreditation process. First, it establishes national standards for comparison, it focuses on improvements to care and service, it improves cross-functional integration, it requires the plan to know its partners and suppliers inside and out, it builds a baseline for quality improvement and it documents the organization’s quality program.

CIGNA HealthCare’s Preparation Process

CIGNA HealthCare of Arizona is a managed care organization (MCO) operating in the state of Arizona. It comprises three health plan divisions with more than 2,000 employees serving more than 450,000 members. It offers a full range of commercial HMO, Medicare risk, Medicaid, individual and preferred provider organization (PPO) products. The Phoenix Staff Model was awarded full three-year accreditation through February 1998, while the CIGNA Private Practice Plan and the Tucson Mixed Model received full three-year accreditation through July 1998 following re-reviews conducted in July 1996.

CIGNA HealthCare was committed to achieving NCQA accreditation. To meet this commitment, a comprehensive corporate approach to preparing for the accreditation survey was developed. To begin, a national NCQA functional training program for all CIGNA HealthCare quality managers was developed. This training consisted of corporate matrix partners ownership for each of the six NCQA standard categories, break-out training sessions for each of the six categories and the development of a standard format for showing compliance with all NCQA standards.

A Corporate Accreditation Unit was created with knowledgeable staff designed to assist CIGNA health plans prepare for their survey. An accreditation site manager was assigned to each health plan. Monthly conference calls were conducted by each site manager, along with the distribution of a monthly communication package, to share best practices and lessons learned from all health plans.

Preparing for the Survey

A staged preparatory program consisted of a Kick-off (12 months prior to survey), a site assessment (nine months prior to survey), a mock NCQA review (six months prior to survey), a post-mock site assessment (three months prior to survey), the NCQA survey and a post NCQA survey assessment. This was developed to ensure all health plans were adequately prepared for their accreditation survey.

An NCQA Compliance Scoring Action Plan was developed indicating compliance vs. non-compliance with all the NCQA standards. The action plan was submitted monthly to the Corporate Accreditation Unit for a status review. In addition, the action plan was scored at the site assessment, mock review and post-mock review to determine progress toward 100 percent compliance with the NCQA standards.

Locally, CIGNA HealthCare of Arizona created a NCQA Task Force that met monthly and was responsible for reviewing progress and updating the NCQA Compliance Action Plan. As the survey date grew closer, the team met weekly to review progress toward putting together necessary documents.

Teamwork Makes It Possible

A team of more than 30 CIGNA employees worked diligently behind the scenes for several months to coordinate, review and refine the documents that were reviewed by NCQA. But long before the NCQA review, the team began the task of gathering needed documents and preparing them for review by NCQA.

Team member groups became “owners” of one of the six categories. As “category owners,” the team members were responsible for gathering and preparing documents needed to meet the standards within each category. Mentors were assigned to each “category owner,” and were responsible for reviewing the documents within each category and making suggestions for improvement. Finally, one month prior to the NCQA survey, each “category owner” was responsible for conducting a training session during the NCQA Task Force meetings.

Quality Applies to Every Function

The teams were cross-functional, pulling together employees from all CIGNA departments. It’s important to think broadly about quality improvement. It applies to every part of the business. It has to do with patient care, customer satisfaction, service and finances.

There are many costs to preparing for and achieving NCQA accreditation. The NCQA fee itself is expensive. In addition, aggressive timelines can burn people out, resource allocation can force trade-offs with other priorities, conflicting priorities can result in opportunity costs and finally, continuous quality improvement (CQI) can lose focus and direction with the burden of paper and documentation.

Lessons Learned

Some lessons learned include:

* it’s never to early to start preparing for a survey;

* resource conflicts must be resolved early and rationally;

* draw upon a broader base of resources–there are many experts in the industry who can add invaluable knowledge to the process;

* produce and organize volumes of documentation for ease of interpretation;

* demonstrate that your “performance” meets the intent of the standards; and

* manage the NCQA survey preparation as a team and engage your line managers.

Kristi Thomason is the quality director at CIGNA HealthCare of Arizona in Phoenix.

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