Health Call Center Accreditation Standards Summary

Accreditation Overview.

URAC designed the Health Call Center Standards for organizations that provide clinical triage and health information services to enrollees in health plans and patients in a variety of health care settings.

Many health plans, hospitals and physicians’ offices use call centers to guide patients to appropriate settings to seek care. For example, an individual may contact a health call center to describe symptoms he or she is experiencing. The health call center might direct the member to schedule a doctor’s appointment, visit an urgent care center or go directly to the closest emergency room. The standards ensure that health call centers are able to respond to these issues quickly and with the appropriate clinical expertise. This accreditation program also focuses on how health call centers provide support and guidance.

Please note: In addition to the specific standards described below, organizations seeking Health Call Center Accreditation must also comply with the Core Standards.

Scope of Services.

The standards address confidentiality, staff qualifications, clinical decision support tools, communication handling, information upon which clinical activity is conducted, communication documentation and health education. These standards apply to telephone and other forms of communication such as electronic mail, facsimiles, etc.

Personnel.

Non-clinical staff may not perform clinical activities and must be qualified and trained to perform screening of service requests. There must be an established process for promptly transferring telephone calls or other communications requiring clinical attention to a licensed clinical staff person and monitoring of the non-clinical staff by a licensed clinical staff person. Registered nurses, physicians or other licensed health care professionals may perform clinical triage and health information services.

Anyone performing clinical services must hold either a current, unrestricted license or a current certification from an appropriate national accrediting body.

Operations/Process.

Staff identifies themselves by first name, title and company name. Staff responds to questions from callers regarding policies and procedures for clinical triage and health information.

There should be a program to continuously monitor all incoming telephone calls using indicators such as average blockage rate (the caller gets a busy signal), average speed of answer by a live person and average abandonment rate (the caller hangs up due to excessive waiting on the line). If a clinical staff person does not directly answer a clinical call within 60 seconds there must be a process that instructs the caller to dial 911, remain on the line or to leave a message. If the organization receives communications other than through the telephone, the organization maintains policies and procedures to address timeliness of responses.

A clinical staff person responds to clinical triage communications within an average of 30 minutes and communications for health information within one business day. The organization ensures that the consumers’ physician receives clinical recommendations, if requested by the consumer.

The organization documents non-automated incoming communications according to policies and procedures and has a mechanism to retrieve these records of communication. The organization also documents all follow-up communications. The organization has a mechanism to monitor and report the aggregate disposition of clinical triage communications.

The organization participates, to the extent it is contractually responsible for such activities, in the education of callers by making available information and educational materials on available health care services and programs, prevention services and community services.

Quality Improvement.

The organization uses clinical decision support tools developed with the involvement of actively practicing physicians and based on scientifically valid clinical principles and processes. There must be an annual review and update of the tools. The organization uses the results of quality review studies to update clinical decision support tools.

Confidentiality.

Organizations conducting clinical triage and health information activities implement mechanisms to ensure that individually identifiable information and provider-specific information are protected. The organization may only release individually identifiable information in accordance with applicable federal and state laws. They may share the information only with staff authorized to receive this information and in need of the information. If the organization releases provider-specific data to the public, it must show how it obtained the data, that the data is accurate, how it may be used and how it complies with applicable laws.

The organization shares all clinical and demographic information on patients among its various clinical divisions and administrative departments. The organization may only collect data that is necessary as indicated by operational policies and procedures and clinical decision support tools.

CLICK HERE for a list of standards you must comply with in order to obtain accreditation.

Created by Matrix Group International, Inc