Review & Future Plans for Quality and Utilization Management Programs

The Quality and Utilization Management Program at a large community hospital was felt to be an important influence on patient care management processes. It has been cited as a benchmark program for external facilities as an example of successful approaches to managing resources and patient access to hospital services. In light of the changes within the hospital and in the external community, a project was initiated to conduct a review to determine future plans for this program within the hospital.
Through consultation with various internal stakeholders, various goals were identified for the review. A confidential, semi-structured interview process was utilized with all stakeholder groups. The final report was structured around the goals, identified common themes and specific key concerns identified in the review process, and included recommendations regarding new structures, adapted processes, and valued elements to retain. Click here to see a Brief Overview.

Therapy Service Delivery Model Project

A community based multidisciplinary care organization is engaged in developing an overview of major client groups, along with consistent therapy service models across all clients and service sites. In addition to the clear picture of major client groups, the key stakeholders in the project group have also identified critical junctures in the client journey. Development of flow charts of the clients’ experiences for the basis of related care management tools. The project management plans take into account the organization’s steps in integrating learning organization processes and attitudes.

Decision Support Framework for a Multi-Site Community Hospital

A large multi-site community hospital used a stakeholder driven process to identify key areas to support with a decision support department. The framework built on skills of data analysis from health records, patient care management from utilization management and pathways processes, and program evaluation processes to support both ongoing hospital program development and the formative evaluation and development of the new department. Challenges included meeting the needs of administrators for decision support when data were not yet available, and developing ways of collecting and communicating information about the data flow, the data message, target patient groups, and summary messages.

Maintenance Program for Utilization Management Process

In addition to daily patient acuity review activities, strategies for targeting patient groups for rotating audits were developed. Feedback processes to physicians at both individual and group level were developed and adapted as the nature of utilization challenges changed due to the impact of the program. A training program in utilization management for patient care facilitators was also developed. The program was based on a scan of the organization for enablers and blocks, as well as the strategic understanding of the organizations issues and goals, industry and government standards and benchmarks. A gap analysis was used as a starting point in planning content. Finally, the development and delivery of both self-learning material and workshops on “ALC” (Alternated Level of Care), addressed strategic utilization issues where knowledge gaps were identified.