Licensure Certification and Accreditation Kaiser Permanente

Kaiser Permanente (N. California) NCQA Accreditation

Kaiser Permanente (Northern California) NCQA Accreditation

Accreditation is a comprehensive evaluation process in which a health care organization's systems, processes and performance are examined by an impartial external organization -- an accrediting body -- to ensure that it is conducting business in a manner that meets predetermined criteria and is consistent with national standards (Iglehart, 1996). The 2010 federal Affordable Care Act (ACA) calls for use of accreditation to ensure quality in the managed health care sector and provide resources to state policymakers through public-private partnerships. Accreditation also helps promote compliance with state law. States use accreditation as a part of their overall effort to evaluate and improve the quality and cost-effectiveness of health care.

The accreditation process seeks to identify best practices and promote continuous quality improvements through ongoing performance measurements (Katzfey, 2004). Specialized advisory groups help to draft and periodically review accreditation standards. The independent evaluation itself typically occurs in two stages, starting with an examination of documentation during an off-site "desktop review" followed by an "onsite survey" of operations (Jaafaripooyan, et. al., 2011). Through the accreditation process, accrediting entities can encourage health care organizations to keep pace with emerging evidence-based clinical and quality improvement standards more readily than if undertaken by legislation or regulation alone (Katzfey, 2004). More than 30 organizations accredit health care companies in the U.S., encompassing all sectors of the health care industry.

Kaiser Permanente is the nation's largest nonprofit health plan, serving 8.4 million members and 140,000 employees and physicians, in nine states throughout the U.S. (including California) and Washington, D.C. (Kaiser Permanente, 2012). Kaiser Permanente actively pursues National Committee for Quality Assurance (NCQA) accreditation and compliance as a way to demonstrate value and quality to purchasers and consumers. The NCQA is an independent organization that reviews the quality and medical management systems of managed care organizations (Iglehart, 1996). It establishes itself as a reliable, independent source of information and recognizes an organization's performance in complying with specific quality standards -- those intended to help an organization achieve the highest level of performance possible, reduce patient risk, and create an environment of continuous quality improvement (Iglehart, 1996).

Organizations are ultimately evaluated against approximately 60 standards for quality in seven categories, including: quality management and improvement; accessibility, availability, referral and triage; utilization management; credentialing; member rights and responsibilities; and clinical evaluation and treatment records. In 2011, Kaiser Permanente Northern California (flagship location) achieved an excellent, four star rating in the follow health plan areas: access and service, staying healthy, getting better, and living with illness. This is the highest possible rating in these categories. A three star rating was achieved for qualified providers (Kaiser Permanente, 2012). To accomplish this, Kaiser senior management positioned NCQA accreditation as an enterprise priority and approached it as a process, not a project -- an effort that required altering the organizational infrastructure to create an environment for continuous quality improvement for care and service delivered to members (Greenfield & Braithwaite, 2011).

One primary goal was to learn how to interpret and apply NCQA standards. To expedite this, key individuals were designated as standard owners and were held accountable for ensuring that Kaiser was meeting or exceeding each of the standards and documenting and providing evidence of both corporate and regional compliance (Evans, 2011). During the accreditation process, Kaiser developed a greater appreciation of the importance of documentation. Although the company conducts a variety of quality improvement activities, without a paper trail, it is impossible to demonstrate that they actually occurred or that meaningful improvement was achieved as a result. Therefore, Kaiser formalized the process in order to better document the company's achievements in this area (Jaafaripooyan, et.al., 2011). This included program descriptions and work plans, evaluations and activity summaries.

Consultants were engaged to assess where Kaiser stood relative to the NCQA standards (Kaiser Permanente, 2012). They identified areas for improvement and returned every six months to review corporate and regional progress. They also conducted mock site visits that required preparation of all documentation required in an actual NCQA site visit, including committee meeting minutes, credentialing files, and QIA summaries and evidence. Staff were also interviewed as a means of preparing the actual site visit (Evans, 2011). The formal NCQA team included physician reviewers and administrative surveyors who conducted reviews and interviews over a four day on-site visitation. Senior leadership and over a dozen staff members were interviewed. Kaiser was awarded full Health Plan Accreditation which will remain in effect until March 17, 2014. The next review is scheduled for October 8, 2013 (Kaiser Permanente, 2012).