MHR's Tips on Organizing Your NCQA Documents

By Nancy Ross Bell, RN

Estimated time to read: 5 minutes

Whether packing up to move to another city or spring cleaning your home, you likely went through a process of items to keep, trash, recycle, or donate. Document management before and after an NCQA survey can be similar.

One key to a successful survey is having your documents in order from one survey to another. Having what you need and being able to retrieve it easily can make your survey preparation more efficient and help you sustain accreditation after your survey is complete. Contrarily, disorganized document control and saving too much can only add complexity to an already complex process!

How to Decide?

Three categories to consider are:

1. Documentation (documented processes, reports, or materials) applicable throughout the look-back period
2. Documentation under a Scope of Review that specifies NCQA will review the organization’s most recent and previous year’s reports
3. Documentation (documented processes, reports, or materials) of an organization’s historical documents

Throughout the look-back period

The look-back period for each Element is specific for Interim, First, and Renewal Surveys. MHR recommends that all documentation used for Interim or First Surveys be maintained as a backup for Renewal Surveys. Documentation for Renewal Surveys should be maintained until the next Renewal Survey is complete.

Examples of documents that are dated to support the look-back periods are the following:

• Minutes for governing boards and quality committees
• Emails, letters, or memorandum of significance
• Letter templates in effect
• Notifications to members and providers
• Strategic decisions impacting programs
• Mergers, acquisitions, or consolidations
• Contracts, agreements, and amendments with effective dates
• Corrective Action Plans (CAP)
• Methodology used for data collection and file reviews
• Annual Analysis Reports (must be done every 12 months)

 What does not need to be retained?

• Document drafts that preceded a final and signed version
• Documents from task forces or subcommittees that rolled up to a larger quality committee where decisions were made

Recent and Previous Year’s Reports

NCQA specifies whether reports from a previous year will be reviewed in an Element’s Scope of Review/Documentation. For example, the ones from the PHM standards are listed below. The recent and previous years' annual reports can be saved and presented in one PDF for surveyor review.   

• PHM 2B – Population Assessment – Documentation for Renewal Surveys: NCQA reviews the organization’s most recent and previous year’s annual assessment reports.
• PHM 2D – Segmentation: Documentation for Renewal Surveys: NCQA also reviews the organization’s most recent and previous year’s annual reports demonstrating implementation.
• PHM 6A – Measuring Effectiveness – Documentation for Renewal Surveys: NCQA reviews the organization’s most recent and previous annual comprehensive analysis of PHM strategy impact.
• PHM 6B – Improvement and Action: Documentation for Renewal Surveys: NCQA reviews the organization’s most recent and previous annual comprehensive analysis of PHM strategy impact.
• PHM 7D – Review of PHM Program: Documentation for Renewal Surveys: NCQA reviews the organization’s most recent and previous year’s annual reviews, audits, performance evaluations, and four semiannual evaluations.

Historical Information

Caution! While keeping information for historical purposes is important to all organizations, it can also lead down a slippery slope of keeping TOO much.

Common issues to avoid are:

• Keeping “everything just in case…”
• Keeping duplicates in multiple departments, such as an accreditation department, operations department, and personal files
• Keeping documents in multiple systems
• Keeping electronic and paper at the same time
• Maintaining documents outside of NCQA folders for easy finding and access

What we suggest be kept for historical purposes

• Organizational charts over the years
• Presentation slides of opening and closing sessions
• System and data flow changes
• Website screenshots outside the look-back period
• Previous policies and procedures to show the effective dates for the entire look-back period, especially when going from six months to 12 months and 24 months.
• Survey Issues List to act on, close, and be compliant for the next survey
• Work/Project Plan to document requirements for the next survey

TIP: Saving and Retrieving Documents

Decide:

• The algorithm by which your organization’s files are saved, such as date, document name, committee, draft, or final
• The number of draft versions, if any, maintained after they are finalized

Call to Action:

• Ask MHR about our consultation on document management as part of Sustaining Accreditation. 

MHR follows a quality review process for all blogs. Jean Lockington has reviewed this blog on Organizing Your NCQA Documents. Please read more about Jean and the other MHR Consultants on our website.

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