Aug 23, 2023
MHR Sustaining NCQA Accreditation

By Nancy Ross Bell

Word count:  794

Estimated time to read:   4 minutes.

Now that you have celebrated your last NCQA accreditation survey, prepare to sustain your results. To help keep you on track, we offer an approach to Look Back, Look Ahead, and Create a Work Plan. This Plan is separate from your Quality or UM Work Plans.  These recommendations are based on what to do after a First or Renewal Survey. Preparation after an Interim health plan survey is somewhat different.

Look Back

After the NCQA survey results are back, if you used MHR as your consulting firm, your MHR consulting team meets with your NCQA Accreditation Team soon after your survey for debriefing.  Some call this meeting their “post-mortem” or “lessons learned.” MHR is now building this function into the client's Scope of Work as it is an incredibly valuable meeting to position organizations for their next NCQA survey.   

Assess the following:

  • Your final scores compared to your goals and expected results.
  • Elements that scored partially met or not met.
  • Points missed due to:
    •  the look-back period  
    • the timeliness of reports
    • the content in analyses and reports
  • Files scored as partially met or not met.
  • Areas questioned by the NCQA surveyors that need clarification, even if you finally received full credit.
  • What worked and didn’t work overall?

Next, determine why points were missed.

  • Was the look-back period misunderstood?
  • Were analyses not scheduled timely for committee discussion to meet annual requirements?
  • Did analyses have insufficient qualitative analysis?
  • Were opportunities and interventions not identified early enough to connect the interventions to the qualitative analysis?
  • Did team members not know the detail of the standards?
  • Did staff turnover result in a lack of continuity?
  • Did accountable parties not meet their deadlines?
  • Was data inadequate?
  • Was oversight of the survey preparation process lacking?

Make a list of Look Back action items. MHR has a “Before the Look-Back Period” process to position you for your next survey.

Look Ahead

As you look ahead, determine potential impacts, such as adding new accreditation programs (Health Equity) or new Distinctions (LTSS), changes in product lines/products, or expanding into new states.   

Review your quality program. Identify new and continuing opportunities, goals, measurements, interventions, and barriers. Are barriers repeating themselves without demonstrating improvement in metrics? QI processes must keep pace with changes in member populations and practitioners.

Make a list of Look Ahead action items.

Create a Work Plan to Sustain Accreditation

Plan your work and work your plan. Two dates are critical to your Work Plan.

The date of your next Full Survey is scheduled by NCQA once you receive your scores. It is typically three years from the date of your most current survey submission.

The start date of your next look-back period (Year One) begins a year from the month the organization previously submitted its completed survey tool. The exceptions for the 24-month look-back period are credentialing and recredentialing files, which are continuous from survey to survey, and all other file reviews with a 12-month look-back period prior to the next submission.

When creating your Work Plan, add the recommended activities listed below, along with targeted dates and accountable individuals. 

  • Add your Look Back and Look Ahead actions.
  • Update all documents where points were missed, or areas questioned.
  • Audit all documentation, particularly those required prior to and throughout the look-back period (preferably three months before your Year One look-back period begins).
  • Identify when all annual requirements need to be met, including delegation oversight.
  • Conduct a mock file review for each file set (quarterly sample).
  • Run data on file universes to verify inclusions and exclusions when completing the first file review to assure clean file universes.
  • Assess your System Controls.
  • Review member and provider letters against existing and new standards. Letters are modified periodically, which prevents them from being compliant.
  • Monitor NCQA’s FAQs (monthly) and Policy Changes & Clarifications (March, July, and November).
  • Review Delegation Agreements and activities for potential delegates.
  • Add NCQA goals to individuals’ performance planning. When NCQA readiness is a key performance indicator, ongoing compliance is more likely to occur.
  • Purchase NCQA’s new standards, which are published annually for health plans and some other products, but not for all products.
  • Schedule training with MHR.

How can MHR help?

Organizations achieve the greatest value in working with MHR when engagements begin soon after their last survey and before their new look-back period starts. This allows time to conduct a Gap Assessment, coach and train new staff, develop relationships with leadership, and partner on a path to sustain improvements.

Call to Action:    

  • Create your Work Plan.
  • Plan for your “off-cycle” survey year needs, including new standards, templates, training, and consultation with MHR.

 Contact us at or email Susan K. Moore.



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