Do You Have Tracking Tools to Stay NCQA Survey-Ready and Prevent Derailment?

By Nancy Ross Bell, RN

Estimated time to read: 3 minutes

As a quality/accreditation leader, you are expected to be accountable, attentive to detail, and well-organized as you prepare for and maintain your organization’s NCQA Accreditation. This can be challenging without the right tools to keep you on track.

The lack of tracking top-priority actions is one barrier that MHR has identified to NCQA survey readiness.  Why not use tested and reliable ways to help keep you organized and avoid losing points from missed deadlines?

Organizations utilizing tracking tools for top-priority actions are likely to complete tasks more efficiently, accurately, and timely and reduce staffing resources from unnecessary rework and delays.

What Should You Track?

• Critical NCQA Survey Dates trigger other future dates, such as for reporting and committee evaluations, and include:
  • NCQA survey submission date
  • Look-Back period
  • NCQA onsite survey

• Logs are used to help monitor pre-determined actions and detect patterns of compliance, such as:
  • Delegates’ semi-annual/annual reports
  • Notifications to members and providers
  • Committee meeting dates and attendance

• Audits are detailed inspections such as helping to assess staff’s compliance with procedures or changes in IT system readiness. These can include:  
  • Gap Assessments to meet standards’ requirements
  • File review audits
  • Information integrity of modifications for utilization management or credentialing/recredentialing

• Action plans are most often used to meet an established goal(s) and include tasks, accountable persons, resources needed, and targeted due dates, such as:
  • Quality Improvement & Quality Management Action Plan

Ideal Features of Tracking Tools

You likely will agree that wall calendars and Post-it® Notes alone are not ideal when it comes to keeping track of all-things NCQA!  Whether you are using internally developed tools or ones from MHR, some ideal features are listed below as appropriate to the need.

• Easy-to-use spreadsheets with Factor level requirements listed
• Easy to detect when non-compliance is evident (Met/Not Met)
• Calendars to visualize important meetings and deadlines
• Due dates calculated according to your survey date and Look-Back period
• Survey-specific (Interim, First, Renewal) and Product-specific (Commercial, Exchange, Medicaid) requirements
• Clear and concise layout applauded by NCQA surveyors for their ease of review!

 Help! Keep Me on Track!  

Don’t derail from your three-year survey cycle.  Unfortunately, we have seen when organizations have not tracked high-priority items, missed their Look-Back period or other important due date, and scurry to try to come into compliance. MHR has a wealth of tools to help prevent missteps, several of which we call attention to here. 

• MHR’s proprietary Gap Assessment audit tool is our most comprehensive assessment of your organization’s status on requirements at one point in time. Initiated at the beginning of consulting engagements for health plans and MBHOs, it is continually updated as clients close gaps.
  • This tool provides leadership and SMEs with an overview of their readiness, risks, estimated points, and areas for possible auto-credit.  Documents are assessed according to timeframes. When deficiencies are corrected, the status is updated. Compliance is assessed by a percentage of Met/Not Met.

The Gap Assessment is a valuable audit tool that is included with MHR’s consultation for all NCQA programs for which we consult.                                  

• Within MHR’s Delegation Suite are logs for each standard set to monitor delegates’ reporting and audit tools to assess the division of responsibilities for delegates and organizations within Delegated Agreements.
• File Review Audit tools for each standard set provide internal auditors with Excel worksheets to score files by Factor level and tabulate percentage compliance. A summary table helps identify patterns of non-compliance by Factor, which can be used to inform delegates and plan for training if needed.
• MHR’s Calendar for a Quality Oversight Committee Work Plan includes a list of over 40 items to track with the ability to customize as needed. For example, data collection and quantitative analysis for the Annual Population Management Effectiveness report may be targeted for January, qualitative analysis for February, and report presentation to the Committee in March and readily displayed and communicated to SMEs.

How Can MHR Help?

Remain survey-ready by staying on top of high-priority actions. The tools mentioned in this blog are only some of the tools that MHR offers.

Call to Action:

• Don’t hold back! Our complimentary Discovery Calls are a way to ask us questions about How We Work and offer suggestions on tools, templates, and training that may benefit your organization.

MHR follows a quality review process for all blogs. This blog was written with insights from Kim Carpenter-Petit. Please read more about Kim and MHR’s other Independent Consultants at ManagedHealthcareResources.com/About Our Consultants.  

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