URAC Core 4.0 — Performance Monitoring and Improvement (C-PMI)

In this post, I discuss the next focus area in URAC’s Core v. 4.0 accreditation standards, Performance Monitoring and Improvement (C-PMI). You can see all our earlier discussions of Core, generally, and this new version, specifically, at our Healthcare Accreditation and Compliance publication.

Rationale

The PMI focus area stresses the value of measurement of performance, both to assist with accountability, but also to help with comparing results to the organization’s objectives.

Scope

This focus area stresses the importance of an enterprise-wide QM program. Such a program should include measurement, monitoring, and evaluation in the service of quality improvement.

The Performance Monitoring and Improvement Standards and Elements of Performance

As is the case with all its new modules, URAC sets forth its general expectations in its standards and more specific expectations in its elements of performance (“EPs”).

Quality Oversight Procedures and Responsibilities

This standard (C-PMI 1) requires an accredited organization to implement a quality management (“QM”) program. Such a program must involve objective, systematic measurement, monitoring, and evaluation. It must address services and processes, and should be used to guide quality improvement. It has five EPs that flesh out URAC’s expectations around the QM program. It is a re-shaping of the QM standards in Core 3.0 (Core 17–24) and the health plan P-QM standards.

The first EP, Quality Management Program Scope (C-PMI 1–1), requires nothing new when it requires that the QM program:

• cover the functions within the scope of the accreditation (e.g., Specialty Pharmacy, Health Plan, Health Utilization Management);
• establish measurable objectives for QI;
• include strategies — both their design and implementation — for QI; and
• has a defined scope that includes the QM programs goals and objectives.

If your organization is clinical in nature, the measurable objectives must be for the population that your organization serves.

The second EP, C-PMI 1–2, is called Quality Management Program Structure and Oversight. It sets forth six specific requirements for the QM committee, which must:

• oversee and guide the QM program;
• monitor the organization’s progress in meeting its QM objectives;
• be comprised if content experts as appropriate to the scope of the accreditation;
• guide the staff on QM priorities and projects;
• approve QI activities; and
• evaluate periodically the QM program’s effectiveness.

The third EP, Quality Management Program Implementation (C-PMI 1–3), gets into the details of the QI process. That process, which is not materially different than that required by the previous standards, must:

• select quality indicators;
• define metrics for performance;
• describe periodic performance measurement, including time frames;
• involve the valid and accurate measurement of processes, errors, complaints, access, or outcome trends;
• include analysis of these trends to assess whether performance objectives are being met;
• involve the implementation of QI activities to address issues identified in the above measurement and analysis activities;
• involve the assessment of how effective these implemented QI activities are in achieving QM objectives;
• include making changes to QI activities that prove to be ineffective; and
• include periodic remeasurement of performance levels for enough time to ensure sustained improvement.

The kinds of performance measures appropriate for an organization will vary based on the type of organization and the nature of its business. Typical indices include error rates, access to services, health outcomes, efficiency, and consumer or client satisfaction.

The next EP, Data Management and Performance Reporting (C-PMI 1–4), outlines URAC’s expectations regarding data processes around performance tracking. These expectations are worded a bit differently than the previous version of the standards, but don’t seem radically different. The QM program must:

• identify the resources used to collect and use performance indicators;
• include the selection of performance indicators and metrics used to establish performance goals;
• involve benchmarking of the organization’s performance, either against its own data or external benchmarks; and
• attend to data integrity in the collection and analysis of the data used to manage key processes.

The final EP under this standard is Quality Management Program Evaluation (C-PMI 1–5). This is a more detailed version of Core 3.0’s Core 20(i), which merely requires an annual evaluation of the effectiveness of the QM program. This standard explains what that requirement means:

• annual reporting to leadership of the evaluation;
• recommendations to improve QM program effectiveness;
• specific addressing of performance vs. goals, sufficiency of resources, appropriateness of staffing, and assessment of QM program impact.

So, looking back on this focus area compared to URAC’s current QM standards, organizations accredited under a module that includes Core 3.0, PHARM Core 3.1, or one of the other equivalent Core modules will need to make some modifications to their processes, which likely are not currently specific enough in certain areas to get over the higher bar set by v. 4.0.