Ensuring quality and safety

Beneath the visible features of a high-quality behavioral health program is a multilayered organization that depends on the coordination of many systems. While the patient sees mostly clinical personnel, patient safety and positive outcomes are grounded in the quality of core competencies largely unseen and difficult to examine by the general public or even purchasers of care.

URAC accreditation takes into account everything, from the highly visible details to those behind the scenes. URAC accreditation promotes organizational integrity and efficiency, promotes clinical effectiveness and regulatory compliance, and improves the use of information technology. For the consumer, URAC enhances quality by improving healthcare management and by setting standards that empower and protect consumers, and improve consumer safety and education.

Often a behavioral health management organization seeks URAC accreditation for one or several core functions, such as utilization management, case management, and disease management, to improve overall healthcare management. URAC accreditation promotes care coordination across these often siloed functions. The URAC accreditation process requires the organization to have care coordination and communication mechanisms in place that otherwise separate behavioral health from other health management functions, a far less than optimal and all too common scenario.

For example, a patient may suffer from depression alongside a physical illness. URAC accreditation requires organizations to create linkages in care coordination, not only to promote the involvement of a behavioral health team, but to see that all aspects of care management work synergistically, resulting in better care and improved outcomes.

In January 2006, URAC introduced revisions of its clinical accreditation standards for health management programs (including behavioral health management programs), including new requirements for ongoing consumer safety initiatives. Although the revised standards put new emphasis on consumer safety, URAC has long operated with the philosophy that safety is an essential component of overall quality, and that URAC quality standards positively influence consumer safety. Monitoring sentinel events, tracking safety data, evaluating outcomes, using evidence-based medicine, practicing prevention to avoid adverse drug events—these activities are just some of what URAC looks for in accredited behavioral health management organizations to promote consumer safety.

In December 2006, URAC released the first draft standards for pharmacy benefit management programs for public comment, with final standards targeted for release this spring. URAC is introducing the standards for a new accreditation program with the goals of promoting industry best practices, encouraging quality improvement, and protecting and empowering consumers.

Although pharmacy benefit management is often a “downstream” function from behavioral healthcare, it is an important component of the total behavioral health management picture. URAC's new pharmacy benefit management accreditation will provide another point of connectivity to improve quality and patient safety throughout the care management process. URAC's pharmacy benefit management accreditation standards promote patient safety and assure access to needed drugs and pharmacies.

The draft standards also are designed to improve the consumer experience and understanding of how these programs operate, which should help ease the burden of behavioral healthcare providers who often find themselves explaining these programs to their consumers. They establish standard definitions, offer grievance and appeals due process, and assure that health plans and pharmacy benefit management organizations communicate effectively with consumers, providers, and care management organizations to increase medication compliance, reduce medication errors, and prevent drug-drug complications, interactions, and adverse reactions. For the behavioral health community, this downstream accreditation provides a further “safety net” that does not currently exist.

In late 2006, URAC also called for public comment on an initial set of healthcare management service measures, to be applied across many of URAC's accreditation programs (including those applicable to behavioral healthcare management programs). The goal of the proposed program is to create and maintain healthcare management services measures for consumer protection, safety, and quality. URAC will collect relevant information and quality data for comparison across five categories: operational service quality, access to services, clinical decision making/support, quality improvement, and customer/consumer satisfaction. This measurement information from URAC-accredited companies will be aggregated and reported back in a way that allows the accredited organization to measure where it stands compared to its peers, for internal benchmarking and improvement.

In addition, aggregate data and reporting for the public will be introduced that provide industry benchmarking and quality data. The metrics, still under development, focus on the processes provided by organizations and the outcomes linked to them. This is a fundamentally different approach to measuring service quality than the population-based HEDIS measures, which focus on clinical quality through the reporting of administrative data.

Quality improvement doesn’t just happen within an organization—it is an intentional, ongoing pursuit guided by industry-recognized standards and processes. Through accreditation, URAC is a partner to organizations as they seek to improve organizational efficiency and effectiveness and promote quality in healthcare management.

Annette Watson, RN, CCM, MBA, is URAC's Chief Accreditation Officer, Vice-President, and General Manager of Client Services.