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Best practices: A necessity in modern health care
logic, all components of the health care system must demonstrate their use of the best techniques and procedures available. Taking a "best practice" approach meets this requirement. Today's health care settings frequently include utilization management (UM), case management (CM), and 24-hour triage and health information (THI) programs. With increased attention on these programs from government and consumers, the incorporation of accreditation and best practice guidelines is essential to the success of these practices. Before going any further, however, a few definitions are in order:
Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options
n June 3, the board of directors of the American Accreditation HealthCare Commission/URAC unanimously approved new case management (CM) organization standards. The standards, which had been in development for more than a year, will serve as the basis for URAC's accreditation program for CM programs and are the first standards to focus on health benefitsrelated CM at the organizational level. Several years ago, URAC realized that many of the organizations that had achieved accreditation for utilization review were evolving toward a CM model. That was the genesis of URAC's interest in developing standards for CM.
with other services like utilization management or other health benefit programs.
Utilization management, which evolved from the basic principles of utilization review, traditionally focuses on one specific episode of care or treatment. UM is the evaluation of the medical necessity, appropriateness, and efficiency of health care services, procedures, and facilities under the auspices of the applicable health benefit plan. A 24-hour triage and health information program often is the patient's point of entry into the health care system. THI programs usually are managed and run by a health care organization's call center. Call centers are designed to direct and educate callers in need of triage or health information services by advising them on the appropriate use of health care.
In early 1998, a CM advisory committee was convened to develop these standards. In addition to its traditional members, URAC invited numerous case managers to participate in the process. Because of the overwhelming interest in the project, URAC eventually appointed a 30-member committee to develop the standards--the largest committee in the organization's history! URAC's goal was to make the accreditation standards attainable for most CM organizations yet rigorous enough to be meaningful to purchasers and consumers. During the year-long development period, the committee, with input from the public and field testing of the
place in the organization, an activity observed in an another organization, or a practice discovered through research, discussion, brainstorming, or other exploratory technique. A best practice is a service, function, or process that the organization has fine-tuned, improved, and implemented. The goal of a best practice is to produce superior outcomes. "Best" is used in a sense that means "best for your patients or your community" in the context of your regional health environment, your health system's strategies and missions, your organizational or community culture, or your practice systems. The use of best practices gives confidence both to consumers and health care employees. Best practices are those activities that lead to the establishment of benchmarks.
standards, worked diligently to balance these competing interests. Quality management requiremen!s, case manager qualifications, and the appeals process proved to be some of the most difficult issues to resolve. However, if initial reaction is any indication, the final set of stafidards is balanced and fair. The standards primarily are directed at CM organizations that provide services in a health benefits setting. According to the introduction to the standards, "These standards apply to 'case management organizations,' which are defined as organizations and/or programs that provide telephonic and/or on-site case management services in conjunction with a September/October1999
T C M 23
A benchmark serves as a standard by which similar things can be measured. For example, in URAC's 24-Hour Telephone Triage and Health Information Standards, (v. 1.0), Standard THI 27 reads, "The Triage and Health Information Program should achieve and maintain the following minimum monthly performance for incoming telephone calls: 9 THI 27.1: an average blockage rate of 5% or less 9 THI 27.2: an average speed of answer by a live person within 30 seconds 9 THI 27.3: an average abandonment rate of 5% or less This standard serves as a benchmark for 24-hour THI systems and makes it possible to evaluate them objectively. Benchmarking is an ongoing process that involves measuring, evaluating, and comparing results and processes that produce the best results. For example, when evaluating the standard THI 27.2 above, an
private or publicly funded benefits program. Such services may be provided by a stand-alone case management organization or by an organization that conducts case management in conjunction with a range of managed care services, such as utilization management or disease management."
organization might find that callers to its triage system were hanging up after 20 seconds. Conversely, the organization might discover that the 30-second goal itself was causing its workers to cut calls short. Either finding could lead to a restructuring of the "best practice." An objective of benchmarking is to help an organization set higher goals and ultimately improve its performance. The overall goal of benchmarking is to identify best practices that can be implemented to produce these improvements. Learning how to adapt best practices promotes breakthrough process improvements and builds healthier providers, patients, and communities. Best practices certainly are not unique to health care. Businesses, academic institutions, and other organizations have been incorporating best practices into their operating structures for several years. The most common procedure is to identify successful organizations and then find and study the practices that con-
9 Structure and organization 9 Staff structure and qualifications 9 Staff management and development 9 Information management 9 Quality improvement 9 Oversight of delegated functions 9 Case management process
CM is found in a variety of settings and organizational types. The standards are designed to accommodate a wide variety of structures, ranging from stand-alone CM companies to programs that are integrated into the operations of larger managed care organizations. The URAC CM organization standards are divided into these sections: TCM 24
September/October1999
9 Ethics 9 Complaints Two types of URAC standards exist: "shaHs" and "shoulds." To achieve accreditation, a managed care organization must score 100% of the "shall" standards and 60% of the "should" standards. Current "should" standards probably will become "shalls" in the future.
tribute to their success. Next, a set of benchmarks is developed from that study that serve as the best practices model for a company or industry. Although all the best practices of one industry may not apply directly to another, some definitely will, and others can be adjusted to fit the new industry. For example, a best practice in lecturing is to allow student feedback. Applying this best practice to the health care industry allows patients to ask questions and provide feedback. The managed care industry increasingly has been scrutinized during the past decade. New legislation has been introduced in most state legislatures, and several bills have been introduced in the U.S. Congress. In this looking glass atmosphere, it becomes essential that all components of the managed care industry demonstrate a commitment to delivering the best medical care possible. It has become irrelevant whether or not the industry already delivers high quality
Of the 33 standards for CM organizations, eight are "shoulds." URAC's accreditation process is rigorous but also is designed to help the CM organization comply with the standards. When a CM organization applies for accreditation, the application is assigned a number to preserve confidentiality as it moves through the accreditation process. A trained staff member from URAC, an accreditation reviewer, is assigned to the application. The accreditation reviewer first conducts a comprehensive "desktop" analysis of the documentation submitted by the applicant, the purpose of which is to initially determine whether the applicant
care. What matters is that the industry can demonstrate its commitment to such care. The best practice that demonstrates this commitment is the establishment of best practice guidelines.
UM, 24-hour THI, and CM practices increasingly are being used throughout our health care system to meet these goals while promoting improved quality and higher patient satisfaction.
A protocol, guideline, standard, clinical pathway, or outcome can be considered a best practice if it:
The UM/CM Best Practices Conference & Expo in November, sponsored by the American Accreditation HealthCare Commission/URAC and the Case Management Society of America, will provide presentations that accurately describe model best practice programs and provide valuable details on how to replicate them. The conference will feature organizations that can effectively reorganize their programs to promote best practices in UM and CM. Innovative strategies for recruiting, retaining, and training staff to fulfill their roles also will be discussed. Model programs that manage information, including the development of information systems and approaches used to analyze and use data, will be featured.
9 Has been implemented and produces superior results 9 Leads to efficient and exceptional performance in cost, quality, and speed or is innovative 9Satisfies key stakeholders (patients and clinicians) 9 Is recognized either internally or externally as a best practice (an award or published presentation) Best practices are being sought that improve clinical patient and administrative efficiencies, reduce costs in health care, and provide supportive data in growing market shares and contracting.
meets each of the applicable URAC accreditation standards. If the application mate}ial is insufficient to demonstrate compliance with a particular standard, the accreditation reviewer works with the applicant to resolve the issue. Additional information or revisions to the application may be needed. After the desktop review process is completed, the accreditation reviewer calls the designated point of contact to schedule a mutually agreeable date for an onsite visit. The reviewer will provide the applicant with a tentative agenda for the site visit. The purpose of the on-site review is for URAC reviewers to confirm that th~ organization in fact is operating in a manner consistent with URAC stan-
into the varied roles for utilization and CM, and predictive modeling are among the topics to be covered in detail during the day-and-a-haif program. Ethics, outcomes, advocacy, standards, and best practices are the core of the program. Leading edge strategies that address patient and caregiver concerns highlight the standard of excellence of the organizations presenting at this conference. For additional information, see website at www.urac.org or www.cmsa.org. :n C. Taney Hamill is the vice president of business development and Joe Luchok is a communications specialist for URAC. They can be reached at (202) 216-9010. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/102029
Quality management in improvement activities, balancing integrating processes
dards. An on-site review typically includes interviews with the key staff members responsible for implementing the organization's CM functions, including the medical director, quality assurance manager, provider contracting manager, credentialing manager, and others. The on-site review team also examines additional documentation (eg, committee meeting minutes, training sign-in sheets, appeal process documentation, provider credentialing files) to verify compliance with applicable standards. After the on-site visit is completed, and if the review team is satisfied that the organization is in compliance with URAC's standards, the accreditation application is forwarded to the URAC Accreditation
Committee, which consists of representatives from diverse health care perspectives with expertise in accreditation. If this committee recommends approval of the application, it is forwarded to U I-(AC Executive Committee for final approval. URAC expects to issue its first CM organization accreditation in September 1999. For ml~re informatiorb contact URAC at (202) 216-9010 or visit its website at www.urac.org. Guy D'Andrea is vice president of standards for URAC in Washington, D.C.
September/October1999
T C M 25
Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options
n June 3, the board of directors of the American Accreditation HealthCare Commission/URAC unanimously approved new case management (CM) organization standards. The standards, which had been in development for more than a year, will serve as the basis for URAC's accreditation program for CM programs and are the first standards to focus on health benefitsrelated CM at the organizational level. Several years ago, URAC realized that many of the organizations that had achieved accreditation for utilization review were evolving toward a CM model. That was the genesis of URAC's interest in developing standards for CM.
with other services like utilization management or other health benefit programs.
Utilization management, which evolved from the basic principles of utilization review, traditionally focuses on one specific episode of care or treatment. UM is the evaluation of the medical necessity, appropriateness, and efficiency of health care services, procedures, and facilities under the auspices of the applicable health benefit plan. A 24-hour triage and health information program often is the patient's point of entry into the health care system. THI programs usually are managed and run by a health care organization's call center. Call centers are designed to direct and educate callers in need of triage or health information services by advising them on the appropriate use of health care.
In early 1998, a CM advisory committee was convened to develop these standards. In addition to its traditional members, URAC invited numerous case managers to participate in the process. Because of the overwhelming interest in the project, URAC eventually appointed a 30-member committee to develop the standards--the largest committee in the organization's history! URAC's goal was to make the accreditation standards attainable for most CM organizations yet rigorous enough to be meaningful to purchasers and consumers. During the year-long development period, the committee, with input from the public and field testing of the
place in the organization, an activity observed in an another organization, or a practice discovered through research, discussion, brainstorming, or other exploratory technique. A best practice is a service, function, or process that the organization has fine-tuned, improved, and implemented. The goal of a best practice is to produce superior outcomes. "Best" is used in a sense that means "best for your patients or your community" in the context of your regional health environment, your health system's strategies and missions, your organizational or community culture, or your practice systems. The use of best practices gives confidence both to consumers and health care employees. Best practices are those activities that lead to the establishment of benchmarks.
standards, worked diligently to balance these competing interests. Quality management requiremen!s, case manager qualifications, and the appeals process proved to be some of the most difficult issues to resolve. However, if initial reaction is any indication, the final set of stafidards is balanced and fair. The standards primarily are directed at CM organizations that provide services in a health benefits setting. According to the introduction to the standards, "These standards apply to 'case management organizations,' which are defined as organizations and/or programs that provide telephonic and/or on-site case management services in conjunction with a September/October1999
T C M 23
A benchmark serves as a standard by which similar things can be measured. For example, in URAC's 24-Hour Telephone Triage and Health Information Standards, (v. 1.0), Standard THI 27 reads, "The Triage and Health Information Program should achieve and maintain the following minimum monthly performance for incoming telephone calls: 9 THI 27.1: an average blockage rate of 5% or less 9 THI 27.2: an average speed of answer by a live person within 30 seconds 9 THI 27.3: an average abandonment rate of 5% or less This standard serves as a benchmark for 24-hour THI systems and makes it possible to evaluate them objectively. Benchmarking is an ongoing process that involves measuring, evaluating, and comparing results and processes that produce the best results. For example, when evaluating the standard THI 27.2 above, an
private or publicly funded benefits program. Such services may be provided by a stand-alone case management organization or by an organization that conducts case management in conjunction with a range of managed care services, such as utilization management or disease management."
organization might find that callers to its triage system were hanging up after 20 seconds. Conversely, the organization might discover that the 30-second goal itself was causing its workers to cut calls short. Either finding could lead to a restructuring of the "best practice." An objective of benchmarking is to help an organization set higher goals and ultimately improve its performance. The overall goal of benchmarking is to identify best practices that can be implemented to produce these improvements. Learning how to adapt best practices promotes breakthrough process improvements and builds healthier providers, patients, and communities. Best practices certainly are not unique to health care. Businesses, academic institutions, and other organizations have been incorporating best practices into their operating structures for several years. The most common procedure is to identify successful organizations and then find and study the practices that con-
9 Structure and organization 9 Staff structure and qualifications 9 Staff management and development 9 Information management 9 Quality improvement 9 Oversight of delegated functions 9 Case management process
CM is found in a variety of settings and organizational types. The standards are designed to accommodate a wide variety of structures, ranging from stand-alone CM companies to programs that are integrated into the operations of larger managed care organizations. The URAC CM organization standards are divided into these sections: TCM 24
September/October1999
9 Ethics 9 Complaints Two types of URAC standards exist: "shaHs" and "shoulds." To achieve accreditation, a managed care organization must score 100% of the "shall" standards and 60% of the "should" standards. Current "should" standards probably will become "shalls" in the future.
tribute to their success. Next, a set of benchmarks is developed from that study that serve as the best practices model for a company or industry. Although all the best practices of one industry may not apply directly to another, some definitely will, and others can be adjusted to fit the new industry. For example, a best practice in lecturing is to allow student feedback. Applying this best practice to the health care industry allows patients to ask questions and provide feedback. The managed care industry increasingly has been scrutinized during the past decade. New legislation has been introduced in most state legislatures, and several bills have been introduced in the U.S. Congress. In this looking glass atmosphere, it becomes essential that all components of the managed care industry demonstrate a commitment to delivering the best medical care possible. It has become irrelevant whether or not the industry already delivers high quality
Of the 33 standards for CM organizations, eight are "shoulds." URAC's accreditation process is rigorous but also is designed to help the CM organization comply with the standards. When a CM organization applies for accreditation, the application is assigned a number to preserve confidentiality as it moves through the accreditation process. A trained staff member from URAC, an accreditation reviewer, is assigned to the application. The accreditation reviewer first conducts a comprehensive "desktop" analysis of the documentation submitted by the applicant, the purpose of which is to initially determine whether the applicant
care. What matters is that the industry can demonstrate its commitment to such care. The best practice that demonstrates this commitment is the establishment of best practice guidelines.
UM, 24-hour THI, and CM practices increasingly are being used throughout our health care system to meet these goals while promoting improved quality and higher patient satisfaction.
A protocol, guideline, standard, clinical pathway, or outcome can be considered a best practice if it:
The UM/CM Best Practices Conference & Expo in November, sponsored by the American Accreditation HealthCare Commission/URAC and the Case Management Society of America, will provide presentations that accurately describe model best practice programs and provide valuable details on how to replicate them. The conference will feature organizations that can effectively reorganize their programs to promote best practices in UM and CM. Innovative strategies for recruiting, retaining, and training staff to fulfill their roles also will be discussed. Model programs that manage information, including the development of information systems and approaches used to analyze and use data, will be featured.
9 Has been implemented and produces superior results 9 Leads to efficient and exceptional performance in cost, quality, and speed or is innovative 9Satisfies key stakeholders (patients and clinicians) 9 Is recognized either internally or externally as a best practice (an award or published presentation) Best practices are being sought that improve clinical patient and administrative efficiencies, reduce costs in health care, and provide supportive data in growing market shares and contracting.
meets each of the applicable URAC accreditation standards. If the application mate}ial is insufficient to demonstrate compliance with a particular standard, the accreditation reviewer works with the applicant to resolve the issue. Additional information or revisions to the application may be needed. After the desktop review process is completed, the accreditation reviewer calls the designated point of contact to schedule a mutually agreeable date for an onsite visit. The reviewer will provide the applicant with a tentative agenda for the site visit. The purpose of the on-site review is for URAC reviewers to confirm that th~ organization in fact is operating in a manner consistent with URAC stan-
into the varied roles for utilization and CM, and predictive modeling are among the topics to be covered in detail during the day-and-a-haif program. Ethics, outcomes, advocacy, standards, and best practices are the core of the program. Leading edge strategies that address patient and caregiver concerns highlight the standard of excellence of the organizations presenting at this conference. For additional information, see website at www.urac.org or www.cmsa.org. :n C. Taney Hamill is the vice president of business development and Joe Luchok is a communications specialist for URAC. They can be reached at (202) 216-9010. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/102029
Quality management in improvement activities, balancing integrating processes
dards. An on-site review typically includes interviews with the key staff members responsible for implementing the organization's CM functions, including the medical director, quality assurance manager, provider contracting manager, credentialing manager, and others. The on-site review team also examines additional documentation (eg, committee meeting minutes, training sign-in sheets, appeal process documentation, provider credentialing files) to verify compliance with applicable standards. After the on-site visit is completed, and if the review team is satisfied that the organization is in compliance with URAC's standards, the accreditation application is forwarded to the URAC Accreditation
Committee, which consists of representatives from diverse health care perspectives with expertise in accreditation. If this committee recommends approval of the application, it is forwarded to U I-(AC Executive Committee for final approval. URAC expects to issue its first CM organization accreditation in September 1999. For ml~re informatiorb contact URAC at (202) 216-9010 or visit its website at www.urac.org. Guy D'Andrea is vice president of standards for URAC in Washington, D.C.
September/October1999
T C M 25