Utilization management in health care management consists of various activities. The process integrates various aspects of the organization, such as quality, risk, and issues relating to case management. Utilization management is a wide process that requires a mechanism that facilitates shared information with medical staff, admitting staff in the hospital, department involved in the emergency, administration and business units, and management of the hospital, associated clinics, and management of health information. Utilization management in a health care institution requires sufficient resources in terms of the workforce and funds. Utilization management facilitates the review of organizational efficiency and effectiveness in the provision of health care services and ensures that patients and customers in such institutions receive quality services (Payne, 2008).
Elements of Utilization Management
Utilization management also facilitates the management of an organization in the provision of quality services at a relatively low cost. There are various components of utilization management in a health care institution, such as the hospital leadership, physician leadership, information systems, external resources, and internal resources. The hospital leadership in utilization management facilitates the integration of different aspects of the organization, such as medical staff, emergency department, and other departments in the organization, that leads to the effective provision of services to the organization’s clients (Olaniyan, Brown, & Williams, 2011). The leadership of the organization should also facilitate allocation of sufficient resources to facilitate successful implementation of the programs.
The aspect of physician leadership in utilization management is development of good working relationships. This is imperative for successful implementation of utilization management in the organization, since it creates an environment where the hospital staff enhances the planning process of the program. The development of a good working environment by the physicians also facilitates appropriate services delivery to patients in regard to the severity of their conditions and the intensity of care required (Center of Medicare and Medicaid Services, 2012). An involved and active physician or a committee of physicians in the utilization management encourages the medical staff of the institution to be involved in the program.
Effective and efficient utilization management also depends on effective information systems, which involve creative and innovative solutions, facilitating accessibility of data and information in the institution. Information and data systems are essential in determining the focus of organizational resources, as well as the determination of areas that require special attention. The medical documentation process and mechanisms should facilitate the availability of information and data for various users in the institution. Utilization management in the organization should also focus on the internal and external resources that may affect effective and efficient implementation of the program. For example, the factors to consider in the external resources include development of constructive relationships between the institution and the case managers, social workers, nursing homes, and home health staff. In addition, they should also focus on the community health care providers, where the institution is able to follow a patient after discharge and promote health education to prevent unnecessary emergency conditions (Payne, 2008).
The internal resources aspects of utilization management programs require development of current procedures and policies in the institution. These policies and procedures should address various aspects in the institution, such as hospital admission requirements, and facilitate shared information among staff in the institution. For example, the admitting staff needs to work with the nurses, practitioners, and other staff involved in developing procedures, such as surgery and swing bed, depending on the intensity of care required by the patient (Center of Medicare and Medicaid Services, 2012). The utilization management program should also ensure continuous training and education for the staff in a health institution for successful implementation of the program.
Hospital University of Pennsylvania Utilization Management Program
HUP is among the top health care providers in the United States, and utilization management is among the top most concerns for the institution in ensuring delivery of quality services to their clients and patients. This is because the institution has a wide range of clients, such as students and patients. This requires the organization to ensure utilization management facilitates reduction in the cost of providing services, as well as provision of quality services. The utilization management program developed by the institution has been set to facilitate appropriate and efficient use of the services provided in the institution (HUP, 2013).
The program developed at Hospital University of Pennsylvania aims at providing good relationships between physicians and different staff working within the institution. The program also facilitates integration and review of the correctional facilities, which facilitates the provision of quality and cost-effective services, depending on the intensity of care required by the patient. The program also includes frequent development of reports and recommendations about the organization facilities and staff (Saunier, 2011). This facilitates further understanding of the organization capacity, which is essential for improved utilization of the resources within the institution, as well as facilitating maintenance of high quality services.
The organization also focuses on the referral processes and the admission of patients into the institution. For example, the organization develops frequent review launch reports, which monitor the appropriateness and accuracy of the referral or the admission process. The institution has also developed an integrated health information system, which allows the admitting staff to communicate better with physicians and other staff to facilitate effective and efficient delivery of services. The health information system also enables the admitting staff to communicate with site physicians for clarifications that promote accurate decision making regarding admission and referral processes (Saunier, 2011).
The institution has also developed internal procedures and policies, which act as a guide to the implementation of a utilization management program in the institution. The utilization management at HUP also involves review of the inpatients, which facilitate close working with different staff, such as nurses and physicians, to allow for timely discharge of the hospitalized patients.
Compliance of HUP with Recognized Standards of Utilization Management
As a top provider of health services in the United States and the world at large, HUP utilization management program seems to comply with various aspects of utilization management. For example, the development of a health information system in the institution facilitates communication within the institution between different staff. This has been essential in ensuring efficiency and effectiveness of the services provided. This can be attributed to the fact that effective communication between different staff in the institution fosters the development of good working relationships.
The institution has also committed sufficient resources to the implementation of its utilization management program. This has led to the provision of quality services, which are based on continued improvement system, as the organization seeks to achieve higher levels of efficiency and effectiveness in delivery of services. It has also enabled the institution to reduce operation costs, hence increased profitability and efficiency of the organizational operations (Olaniyan, Brown, & Williams, 2011).
However, there are some areas that the institution should consider improving in order to ensure comprehensive implementation of the utilization management program. For example, the organization should consider improving the relationships with the external care providers, such as social workers and community health care providers. This will enable the institution to monitor their clients after the discharge of the patients. This is imperative in ensuring reduction in the number of unnecessary emergency cases in the institution.
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