Discussion: Resource Utilization in Healthcare Services

Discussion: Resource Utilization in Healthcare Services ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Resource Utilization in Healthcare Services Based on the text and supplemental materials about effective resource utilization, describe what you believe to be the major challenges/advantages/flaws/strengths to cost and utilization management in terms of the healthcare quality management approach described in the text you choose. Start by picking a specific approach or setting from the text and extend the ideas and concepts presented in the text with your thoughts and insights to form an evaluation of the value (or not) of that particular approach. Explain your concerns or support for the chosen technique or approach. Discuss the impact of high reliability on the selected approach. Your initial posting should be limited to no more than 4 succinct paragraphs. Focus on giving the other students a clear picture of what you think of the value of the selected approach or technique. Discussion: Resource Utilization in Healthcare Services chapter10_edited.ppt chapter9_edited.ppt Introduction to Healthcare Quality Management Organizing for Quality Quality Does Not Happen by Accident ? Every healthcare organization must create a framework for accomplishing quality activities. ? Trustees and senior leaders must champion an environment that supports continuous improvement. Copyright 2009 Health Administration Press 2 Board Has Ultimate Responsibility ? Legal and moral responsibility for the quality of patient care and services lies with the governing board. ? Personal involvement by board members is a key factor in high-performing organizations. Copyright 2009 Health Administration Press 3 Quality Management System ? Organizational framework that defines and guides all measurement, assessment, and improvement activities ? Varies according to the type and size of the organization, available resources, externally imposed quality requirements, and internal improvement priorities ? Often documented in a quality management (QM) plan Copyright 2009 Health Administration Press 4 Groups Involved in QM Board Copyright 2009 Health Administration Press 5 Common Board Responsibilities ? Create a mission statement that defines the commitment to continuous improvement ? Prioritize organizational quality goals ? Consider QM results in strategic planning ? Learn improvement approaches ? Provide financial support for QM activities ? Promote continuous improvement ? Evaluate progress toward achieving quality goals ? Review effectiveness of the QM program Copyright 2009 Health Administration Press 6 Common Administration Responsibilities ? Define QM infrastructure, assign QM responsibilities, and hold people accountable for fulfilling them ? Allocate necessary resources ? Encourage participation in QM activities ? Promote education about QM concepts and techniques ? Use performance data for strategic planning and new program design ? Identify improvement opportunities and help achieve improvements ? Keep board informed of quality and patient safety issues Copyright 2009 Health Administration Press 7 Common Coordinating Committee Responsibilities ? Meet periodically to oversee and direct QM activities ? Set QM expectations, develop plans, and ensure implementation ? Oversee evaluation of the QM program’s effectiveness ? Communicate QM activities to the board ? Ensure that QM structure and activities meet accreditation and regulatory requirements In a small healthcare organization—such as a clinic— coordinating functions may be done by one person. Copyright 2009 Health Administration Press 8 Hospital Medical Staff Structure ? In a hospital, the medical staff is an organized entity with bylaws, rules and regulations, and a structure for conducting clinical QM activities. ? Joint Commission standards require hospitals to have a medical staff executive committee. ? No other committees are required; however, committees are often used to conduct specific QM functions (e.g., pharmacy and therapeutics committees). Copyright 2009 Health Administration Press 9 Common Medical Staff Responsibilities ? Oversee physician-related QM activities ? Measure, assess, and improve clinical aspects of care ? Evaluate competence of physicians and others who care for patients independently in the organization ? Identify improvement opportunities and help achieve improvements ? Report results of QM activities to the medical staff, oversight committees, and the board If there is no organized medical staff, the medical director or governing board assumes these responsibilities. Copyright 2009 Health Administration Press 10 Common Department Responsibilities ? Managers are responsible for ? providing leadership oversight for departmental QM activities, ? measuring, assessing, and improving clinical and operational performance, ? ensuring the competence of people working in the department, ? identifying opportunities to improve performance and helping to achieve these improvements, and ? reporting the results of departmental QM activities to departmental staff, oversight committees, and the board.Discussion: Resource Utilization in Healthcare Services Copyright 2009 Health Administration Press 11 Quality Support Services ? Common support positions (varies among organizations): ? ? ? ? Quality director Patient safety coordinator Physician quality adviser Case manager/utilization reviewer ? ? ? ? ? Patient advocate Risk manager Infection control coordinator Compliance officer Data analysts The quality support workforce is growing in response to the increasing scope and volume of QM activities. Copyright 2009 Health Administration Press 12 QM Plan ? Document describing the organization’s structure and process for measuring, assessing, and improving performance ? Required according to some accreditation standards and regulatory mandates ? May have one organization-wide plan ? May have an organization-wide plan and plans in each department Copyright 2009 Health Administration Press 13 QM Plan: Quality Statement ? Describes the goal to which all quality management activities are directed Quality statement example: The major objective is to obtain patient outcomes of the highest quality and to provide services that meet or exceed the expectations of our customers. Copyright 2009 Health Administration Press 14 QM Plan: Infrastructure ? Describes major stakeholders and committee structure ? May include illustrations of QM structure or information flow Flow of Performance Information in a Hospital Performance Measures Quality Council System-Level Measures Financial Medical Staff Executive Committee Board of Trustees Clinical Operational Patient safety Customer satisfaction Department-specific System- and Activity-Level Measures Hospital Departments and Multidisciplinary Committees Environment of care Regulatory/accreditation compliance Physician-specific Measures Medical Staff Department Chairs Medical Staff Departments Copyright 2009 Health Administration Press 15 QM Plan: Measurement, Assessment, and Improvement Activities ? May include general statements about QM requirements ? Some plans detail the system-level, departmentspecific, and physician measures of performance. ? May include improvement model(s) to be used ? May include improvement priorities and goals for the upcoming year Copyright 2009 Health Administration Press 16 QM Plan: Effectiveness Evaluation ? Coordinating committee periodically evaluates whether ? quality infrastructure is effective at accomplishing goals, ? quality goals are being met, ? QM program changes are needed to better meet quality goals, and ? new quality goals should be set for the upcoming year. In the absence of a coordinating committee, this evaluation should be done by the board of trustees. Copyright 2009 Health Administration Press 17 The “Jaws of Culture” Often Disrupt Change Initiatives (including QM) Copyright 2009 Health Administration Press 18 Hospitable Environment ? In a culture committed to quality ? senior leaders and managers lead by example and encourage an environment of open, candid dialogue and continuous improvement; ? Discussion: Resource Utilization in Healthcare Services people who do the work are actively involved, and management seeks their views and listens to what they have to say; ? everyone is clear on the expected level of performance and receives feedback on progress; ? people are acknowledged and recognized for their efforts in furthering quality goals; and ? people trust and have confidence in leadership’s determination to continuously improve organizational performance. Copyright 2009 Health Administration Press 19 Leaders’ Contribution to a Supportive Culture ? Demonstrate a leadership style that has an appropriate balance between caring and controlling ? Be visibly interested in performance excellence ? Encourage employees to have a questioning attitude regarding performance issues Copyright 2009 Health Administration Press 20 Leaders’ Contribution (cont.) ? Monitor performance trends to determine whether objectives are being achieved ? Take a genuine interest in performance improvements and recognize those who make them ? Take personal responsibility for directly improving aspects of performance in their area of responsibility Copyright 2009 Health Administration Press 21 Turning Around the Culture ? Understand the severity and spread of the cultural issues affecting quality and safety. ? Conduct baseline and follow-up surveys. ? Expect culture changes to take time (three to five years). ? Determine critical work–culture components that will adversely affect future performance. ? Concentrate change efforts on these components. Copyright 2009 Health Administration Press 22 Quality Does Not Happen by Accident Board ? Effective framework for accomplishing QM activities ? Culture supportive of continuous improvement Copyright 2009 Health Administration Press 23 Introduction to Healthcare Quality Management Managing the Use of Healthcare Resources Utilization Management ? A component of healthcare quality management ? Purpose: eliminate overuse and underuse of medically necessary healthcare services ? Supports one of the healthcare quality dimensions identified as important by the Institute of Medicine (2001) ? Effective healthcare: provision of services based on scientific knowledge to all who may benefit but not to those who are not likely to benefit Copyright 2009 Health Administration Press Why Manage Utilization? Copyright 2009 Health Administration Press Defining Appropriate Care ? Historically, physicians had considerable autonomy in recommending healthcare services. ? Result: considerable variation in use of services among physicians and in different U.S. regions ? In early 1990s, purchasers championed the development of evidence-based clinical practice guidelines to reduce variation in treatment decisions. Copyright 2009 Health Administration Press Clinical Practice Guidelines ? “Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” Source: Institute of Medicine. 1990. Clinical Practice Guidelines: Directions for a New Program, edited by M. J. Field and K. N. Lohr. Washington, DC: National Academies Press. ? In the absence of guidelines, an explicit, evidence- or consensus-based process is used to judge appropriateness of services. Copyright 2009 Health Administration Press Utilization Management (UM) Functions Measurement How are we doing? Yes Assessment Are we meeting expectations? No Improvement How can we improve performance? ? Measure over- and underuse of health services ? Assess measurement data to identify improvement opportunities ? Use improvement techniques to reduce over- and underuse of health services Copyright 2009 Health Administration Press Required UM Functions ? Medicare Conditions of Participation mandate that providers conduct UM. ? There is no explicit UM requirement in Joint Commission standards. ? Providers assist health plans with UM activities by providing patient-specific information. Copyright 2009 Health Administration Press Measurement and Assessment ? Utilization review ? Ensure that services are medically necessary and appropriate Discussion: Resource Utilization in Healthcare Services ? Promote delivery of services in the most costeffective setting Copyright 2009 Health Administration Press Timing of Reviews ? Prospective ? Before delivery of services ? Ensures that services to be provided are appropriate for the patient and will be done in the least costly setting ? Concurrent ? During delivery of services ? Ensures that services are appropriate for the patient and are provided in the least costly setting Copyright 2009 Health Administration Press Timing of Reviews ? Retrospective ? After delivery of services ? Identify opportunities to reduce over- and underuse of services Average Cost of Hospitalization for Medicare Patients with Pneumonia Hospital National $5,328 $5,000 $4,451 $4,497 $4,417 $4,216 $3,935 $ 3,000 2006 2007 Copyright 2009 Health Administration Press 2008 Source of Utilization Comparison Data ? Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality contains the largest collection of U.S. healthcare utilization data (http://hcupnet.ahrq.gov). ? Example of data available on hospitals: ? ? ? ? ? ? ? Number of discharges by diagnosis/procedure Length of stay by diagnosis/procedure Total charges and costs by diagnosis/procedure Percentage of patients who died in the hospital Percentage of patients admitted through the emergency department Percentage of patients admitted from another hospital Percentage of patients admitted from a long-term care facility Copyright 2009 Health Administration Press Utilization Improvement ? Any improvement model may be used to reduce over- and underuse of resources. ? Common job aids designed to promote use of evidence-based patient care practices: ? Reminders ? Clinical paths ? Standards of care Copyright 2009 Health Administration Press Reminders Purpose: to remind caregivers to perform a specific task Tag on blood container reminds nurse to positively identify patient before starting blood transfusion Copyright 2009 Health Administration Press Clinical Path Purpose: to remind caregivers of interventions and milestones expected to occur during an episode of care Excerpt from Pediatric Pathway for Hospitalized Patient with Non-Ruptured Appendicitis Copyright 2009 Health Administration Press Standards of Care Purpose: to remind caregivers of “ideal” practices Standard Physician Orders for Patients Seen in Emergency Department for Treatment of Chest Pain Copyright 2009 Health Administration Press Discharge Planning ? Establishes a systematic approach to ensuring effective utilization of patient care resources and a smooth transition from one environment to the next ? Organizes care activities suited to the patient’s needs ? Supports the goal of patient-centered care; one of the healthcare quality dimensions identified as important by the Institute of Medicine (2001) Copyright 2009 Health Administration Press Discharge Planning Services ? Accreditation groups and health insurers, including Medicare, require healthcare organizations to provide discharge planning services for patients. ? Discharge planning for patients with special needs is often done by case managers. Discharge Planning Activity Tasks Initial patient assessment • • • Gather history (social and medical) Evaluate medical condition and treatment needs Assess support systems (e.g., home environment, community resources, family needs) Plan for continuing care • • • • Identify short- and long-term patient care needs Prioritize needs according to input of patient and family Consider available human, financial, and material resources Update plan according to patient’s condition Implement plan • • Arrange for services and support that patient requires after discharge Provide patient and family information about post-discharge treatment plan, services, and support EvaluateDiscussion: Resource Utilization in Healthcare Services • Follow up with patient or family after discharge to assess whether plan was successful and to ensure that no problems arose after discharge that have not been addressed Copyright 2009 Health Administration Press UM Structure ? Medicare requires providers to have a defined UM structure that accomplishes specific tasks. ? Hospitals must have a utilization review committee with physician members. ? Utilization review activities are required for admissions and continued stays. ? Discharge planning services are required. Copyright 2009 Health Administration Press Health Plan Utilization Review ? National Committee for Quality Assurance sets accreditation standards, and most state insurance regulations require utilization review activities. ? Clinical professionals are involved in evaluating over- and underuse of services. ? There are no incentives for denying, limiting, or discontinuing services that are medically necessary. ? A defined process is established for approving and denying payment for services. Copyright 2009 Health Administration Press Utilization Management ? UM has been a component of quality management since the inception of Medicare in the 1960s. ? The goal is to provide appropriate patient care in the least costly setting. ? Measurement, assessment, and improvement activities are used to minimize costs and promote effective use of healthcare resources. Copyright 2009 Health Administration Press … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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