Jun 15, 2023
MHR NCQA Gap Assessment


Word count:  657

Estimated time to read:  4 minutes

Are we making progress? Are we at risk? Do we meet requirements? Could we pass our survey in our present situation? If you are asking yourself these questions, why guess when your organization can have an objective evaluation of where you stand for your next NCQA survey? MHR consultants use a comprehensive process with proprietary tools to help ensure your eventual readiness.

 What is a Full Gap Assessment?

MHR’s Full Gap Assessment is a virtual, systematic, and very detailed method of evaluating your processes, reports, materials, and files. It includes an evaluation of delegation arrangements and documentation and whether auto-credit may be applied. This results in an estimated risk level and an approximation of points towards accreditation and is a snapshot in time of your status if the survey occurred at that point for your specific type of survey and lines of business. This high-value consultation helps the organization:

  • Know its areas at no or low, moderate, or high risk
  • Know which factors and elements are met or not met
  • Know the estimated points achieved for each standard set
  • Provides a baseline of readiness.

MHR’s proprietary tools are customized for each type of accreditation and have the points for that standard year embedded in the tool. They are interactive and enable the organization to identify priorities, track progress, and gauge its preparedness.

The Full Gap Assessment gives the organization clear direction on its path forward where effort, resources, staff training, or system corrections may be needed. Staff and leadership are more informed and confident of their preparedness.

Who needs a Full Gap Assessment?

Organizations pursuing any accreditation benefit from a Full Gap Assessment, whether it’s the first time pursuing a survey or a Renewal. Changes in standards, staff, workflows, delegates, additional lines of business, and Distinctions, etc., can change over time, necessitating a new evaluation.

When is the best time to have a Full Gap Assessment?

MHR conducts its Full Gap Assessment at the initiation of an engagement with our clients. 

Ideally, all assessments should be done before your look-back period.  Credentialing files are a top priority because of their ongoing look-back period, except for Initial surveys, which is six months.

How long does a Full Gap Assessment take, and how is it done?

The time it takes to complete an assessment depends largely on the organization and its readiness to supply MHR with all completed documents and access to files. Additionally, the preparedness of the files with highlighting and bookmarking will expedite the evaluation process.

After a kick-off meeting, you can expect the following.

  1. We ask that you send us a series of documents within your look-back period, with all PHI redacted, including:

- A list of delegates, your pre-delegation assessments as appropriate, Agreements, minutes from collaborative meetings, and oversight reports

- Documented processes as specified by the standards

- Screenshots for elements required throughout and/or within the look-back period

- Standards with must-pass elements and critical factors

  1. MHR evaluates all documents according to the standards, identifies any gaps, and assesses a score for each factor.
  2. Next, we assess a sample of all files within your look-back period, as appropriate to your survey.  Our sample review requires limited system access to examine the fields necessary to score the files and is now conducted virtually. Staff navigate the system and present files through password-required web platforms.  
  3. At the conclusion, you receive project management files detailing your risk levels, percent scores, current points, gaps, and actions to close gaps.

How can MHR help?

MHR’s Full Gap Assessment is comprehensive and detailed.  We are leaders in partnering with organizations to prepare for their surveys. Using this tool as a starting-off point, you can be assured that we support you at each step!  

Call to Action:  

  • Contact MHR for your Full Gap Assessment before your look-back period begins. See “Contact Us” at:

Email To: [email protected]


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