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Index - Major Sections
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Utilization ManagementThe responsibility for the utilization management function belongs to the governing board of the health care organization. It is the board’s job to ensure that the process is carried out correctly. The board may choose to incorporate the peer review process into the finance division, the quality assurance department, or even social services. The most common model is a department under which is placed quality assurance (or quality improvement), risk management, and utilization management The committee is to develop a written plan as may be required by certain agencies. The plan identifies authority and responsibility for the UM process, accountability and reporting structures, the role of the physician advisers, the review mechanism, and the mechanism for handling review decisions and appeals. It requires that review be done in a timely manner and on a consistent basis. Although committee membership may vary according to whether it is a separate group or part of another, there are certain members that need to be included. Since it is a committee of the medical staff, it should primarily be composed of physicians from the staff representing all departments. Non-physician members of the committee vary accounting to the structure of the organization. The inclusion of non-physicians, such as nurses and financial staff, gives a broad perspective to decisions because no one member is likely to fully understand the ramifications to the other departments. The committee also determines the system to be used for physician advisers (PAs). Some hospitals have a rotating schedule assigning each physician a time in which he or she functions as physician adviser. Others have permanent PAs that are full time and paid. Others have variations of one of these plans. Although it is a peer review process, the physicians cannot be expected to review the care of each patient admitted to the hospital; it wouldn’t be a good use of resources. Instead, the physician committee sets up a mechanism for review, as well as for referral, and it sets up criteria for the nurse reviewers to use. The mechanism for review includes guidelines on who is to be reviewed. It must be decided if all cases are to be reviewed. It must be decided whether all cases are to be reviewed on admission, or only certain cases and how those cases are to be chosen. An example of a plan could be that all cases are reviewed on admission except for routine deliveries unless the mother or infant are hospitalized longer than two days. The mechanism for referral states at what point the physician adviser is to be notified and asked to review a case. Typically, this is when the criteria are not met or when something difficult to understand is occurring. In reality, it is often difficult to arrange for the designated physician adviser to review a chart when needed. His or her own practice and schedule often conflict, and delays result. Because of this, plans that are arranged so that a certain PA is available every day at a certain time often work better. When PAs review a case outside their specialty, they contact another committee member who is in that field. This is the reason for staffing the committee with a variety of specialists. ReviewA review is an analysis of the medical necessity and appropriateness of care the patient receives. It can be done for a variety of reasons, at many times and in many ways, but it is always an impartial appraisal of the care, which is documented in the medical record.
Concurrent review occurs when the patient is receiving the care being reviewed. Concurrent review provides an opportunity to have an impact on the length of stay and the quality of care received. Retrospective review occurs after the patient has been discharged or is no longer receiving the service. Retrospective review may collect information, but since the care has already been received, it leaves no room for intervention. Nonetheless, the health care given still needs to be verified for medical necessity and appropriateness. Both reviews give the organization an additional opportunity to collect data on trends and patterns in care Methods of ReviewKnowing what information to include in a review takes skill and practice, but is logical. A concise picture must be painted of what is happening to the patient and why. The reviewer must collect, process, and summarize a great deal of information so that it produces a meaningful statement of the patient’s condition. It is not simply copying down every order the physician wrote or the results of every lab test. It is understanding what those orders and tests mean and how that affects the patient. The reviewer must use his or her knowledge of the disease process to anticipate what would occur next or which complications are being expected given the tests ordered. He or she must grasp the significance of an abnormal lab result and understand why others have been ordered. The data that comprises this review begins with the medical record. The more complete and through these records, the better able the reviewer may judge the quality of medical care. Since in many cases it is not possible for the reviewer to see the client, the documentation is all that can be used to access the quality of care. The reviewer must answer the following question. .
CriteriaWebster’s Dictionary defines a criterion as “a standard on which a judgment may be based.” The criteria are not law; they are not perfect. Patients often do not fit any predetermined characteristics. As such, they often do not fit criteria. The criteria are used simply as a tool to separate the easily classified from the others. Those that are not easily classified are referred to a physician adviser or undergo other scrutiny. UM committees must choose a set of criteria to be used for the review process. Some organizations develop their own criteria, but that is time-consuming. A health care organization may purchase one of the commercially available pre-developed sets. Some of the most widely used are:
The SI/IS set includes generic criteria that are applied first. If they aren’t appropriate, other criteria can be chosen from the body system affected. The criteria list specific symptoms, lab results, and treatments that will qualify a patient for hospitalization. For example, if there is sudden onset of paralysis, acute hemorrhage, a WBC greater than 25,000, ventilator-assisted breathing, or any number of other specific occurrences, the admission will be approved. The Milliman and Robertson ORGs are configured differently. They are not unlike critical pathways in that they give expected behaviors that will be seen daily in the progress of a patient with a specific diagnosis. If the patient follows the guidelines, discharge will be anticipated when the ORGs state. If a patient does not meet the daily steps indicated, then there must be medical necessity to explain the variances. |
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