Introduction to the Healthcare Facility

Introduction to the Healthcare Facility
Introduction to the Healthcare Facility

Introduction to the Healthcare Facility

Order Instructions:

The Session Long Project for this course is to evaluate and critique a health care facility you are familiar with and compare it to the general principles and standards for quality assurance presented in this course.

In the earlier modules, you identified a health care facility for the subject of the SLP and presented a description of the facility and its quality assurance program. You also critiqued the facility’s Continuous Quality Improvement program.

In this module, you will discuss and critique the subject facility’s Utilization Management program. The remaining modules for the Session Long Project the remaining tasks are as follows:

SLP Assignment Expectations

For this module, you are to complete the following tasks and to submit a 4- to 5-page paper. (This does not include the title or reference pages):
•Describe and discuss the facility’s Utilization Management program.
•Compare and critique the subject facility’s Utilization Management program to that of a model facility and whether the facility adheres to the recognized standard for utilization management, including utilization review and whether this review leads to improvement in the quality of care.
•Identify areas for improvement in the facility’s Utilization management program, if any, and any recommendations you think should be implemented to improve the quality of patient care.

Module Overview

Utilization Review (UR): A system designed to monitor the use of, or evaluate the medical appropriateness, efficacy or efficiency of health care services, procedures, providers or facilities. utilization review may include ambulatory review, case management, certification, concurrent review, discharge planning, prospective review, retrospective review or second opinions. NCGS 58-50-61(a)(17). (Refer to Glossary at


Utilization review is an important component of a quality assurance program. It is intended to monitor the care provided to patients and to detect patterns of over and underutilization. However, utilization review doesn’t stop at this point. It moves ahead by taking the utilization data and changing utilization practices among practitioners and providers to improve quality and promote effective utilization of medical resources.

In many medical facilities, utilization review extends to outpatient review services by reviewing requests for elective procedures and diagnostic testing. Utilization managers and staff will then work with the attending physicians to determine if clinical data support the benefits covered for the requests. In some medical facilities, this is called Demand Management.

Utilization review, or UR, as it is frequently called, was originally intended as a vehicle that addressed cost containment rather than the adequacy of patient care. Basically, UR is a cost containment technique.

UR can occur retrospectively or prospectively. When it is conducted retrospectively, it is primarily concerned with the review of services already rendered; however, when it is conducted prospectively it is used to authorize or refuse proposed treatments, referrals, and even hospital admissions. In the perspective mode, UR may have severe time restraints which if not met may cause harm to the patients. Medical conditions/diseases do not remain static during utilization review.

Another issue regarding UR is whether the employees or agents of a managed-care organization are practicing medicine when they make a determination whether a requested treatment is medically necessary.

Utilization review is an integral part of quality assurance. If managed properly it certainly can results in a higher quality of care while controlling costs. However, if and organizations’ utilization review program is inefficient and poorly managed it has the potential to harm patients and lower quality of care.

Required Reading

Anonymous. (2013). Does your organization have a utilization management committee? Medical Staff Briefing, 23(11), 1,3-5.

Frazier, K. (2014). Utilization Review Software: The Impact on Productivity and Structural Empowerment in Case Management Nurses in an Acute Care Setting. Gardner-Webb University.

Koike, A., Klap, R., & Unützer, J. (2014). Utilization management in a large managed behavioral health organization. Psychiatric Services.

Mullahy, C. M. (2014). The Case Manager’s Handbook, (5thed). Burlington, MA: Jones & Bartlett Learning. Retrieved from

NHS England provides funding for clinical utilization review programmes to improve patient flow. (2014). Professional Services Close – Up, Retrieved from

Olaniyan, O, Brown, I. L., & Williams, K. (2011). Concurrent utilization review; Getting it right. Physician Executive, 37(3), 50-54.

Plebani, M., Zaninotto, M., & Faggian, D. (2014). Utilization management: a European perspective. Clinica Chimica Acta, 427, 137-141.

Tubbs, S. L., Husby, B., & Jensen, L. (2011). Ten common misconceptions about continuous improvement efforts in healthcare organizations. The Business Review, Cambridge, 17(2), 21 – 28.

Sample Answer

Introduction to the healthcare facility

The healthcare facility identified is  Durham Veterans Affair healthcare (VA) in North Carolina. The healthcare facility provides services to military members, their families, and the retired veterans. The services provided in this healthcare facility include primary care, surgical services, audiology, ophthalmology, inpatient services, and outpatient services. It also has other ancillary departments such as laboratory and radiology departments The department has operating rooms for regular surgical procedures, cytography and angiography. All the healthcare departments in this facility must follow quality assurance procedures established by its department (, 2015).

Utilization Management Program

The VA Durham utilization program is design in a manner that ensures delivery of quality and cost effective care to the service user. The utilization program is under the administrative and clinical direction  of the Medical advisory council and the Medical Advisory  vice president. The Medical advisory council is mandated to evaluate and approve the utilization management program every year.  In my place of work, the utilization program is manual. The overview of VA utilization management plan is a follows (, 2015);

Referral system: All referrals are to be made by the Primary Care Physician (PCP) after consultation with a specialist at any time. However, no referrals are needed to treat emergency medical condition  unless it puts the patient’s health in jeopardy, potential impairment of body functions and dysfunction of a body organ.

Tertiary plan care: All tertiary care plans should be reviewed on an individual basis based on the patients immediate medical need and its availability. The specialist final decision of referrals will be evaluated by the  plan medical director.

Out-of-Plan Referrals: The requests  of healthcare provider outside  the health facility will be done on an individual basis based on the availability and patients needs  unless the patient’s  health status could be impacted negatively if out-of- plan referrals is denied.

Corporate Pre-service Review: Approval must be given before providing services. The main reason is to determine if the services is appropriate for the patient and the setting. Clinical information must be provided for all healthcare services that need clinical review. The Utilization Management staff should use plan documents to determine patient medical necessity coverage and  determining their benefits. Clinical information needed for clinical review  should be provided on the appropriate date and time. The clinical information must contain patient name, history of presenting disease, diagnostic results and the patient’s response to current treatment.

Inpatient  review: The staff assigned to follow member at  the acute care facility should collaborate with the facility healthcare providers so as to ensure ca continuum of care. The  facility staff and utilization management’s clinical staff will work in coordination to ensure that member’s discharge needs are met. All inpatient  should be reviewed before their admission to ensure that they have appropriate and adequate services according to pre-established medical necessity and benefits determinants. The admission will be approved accordingly of rescheduled  in appropriate timing and setting.

Concurrent review: The ongoing patient care will be reviewed and evaluated based on patients specific needs and  pre-established medical necessity. Discharge planning can begin at this time so as to plan for continuing quality care even after the patient is discharged.

Retrospective review: is performed after discharging the patient from a  healthcare facility. This should be implemented at when so as to monitor a patient’s progress after the patient was discharged when a physician was unavailable or when the healthcare facility fails to demonstrate that the patient condition meet criteria for a patient stay.

Discharge planning: the utilization manager coordinator will monitor the ongoing needs for the patient after discharge. Few days after discharge, follow up  phone calls should be done so as to identify members at high risk of becoming admitted. This is to ensure that the quality assurance is complied to and to assist in care coordination so as to  mitigate adverse outcomes.

Denials and Appeals: All denials will be given by the physician and must state the denial reason and contact information to discuss the denial. A written denial will be written and emailed to the Utilization management committee.

Critique of VA utilization management program

The main challenge of VA utilization program at my work place is that  it is an expensive manual resource that fails to engage the providers adequately, and often results into inefficient service for the service users (Anonymous, 2013).  For instance, 90% of pre-authorizations need  phone communications, which is time consuming and costs  up to $50-$80 costs per each authorization. In addition, it is estimated that about 15% of medical care procedures are unnecessary such as duplicative tests and hospitalizations.

Most of these  costs are attributable to inconsistencies observed during clinical decision making that occur when relying on the traditional manual utilization management processes and the incomplete coverage as necessary.  In addition, when healthcare providers have to wait until healthcare is delivered to deliberate on the event, it leads to missing of opportunities that will ensure cost effective quality care. In addition, the pre-authorization process that follows manual process  requires a great deal of investment as compared to an automated system that facilitates immediate approvals upon request, and to providers with appropriate guidance based on evidence based practice (Mullahy, 2014).

Areas for improvement in Utilization Management program

Some utilization management program changes will occur in the VA utilization program.  The driving force  for most of these changes includes advancement in organizational relationships and utilization management technologies. Effective utilization management is based on its ability to provide detailed yet coherent clinical information, and in providing clinical guidelines that define the most effective and appropriate care that will ensure positive patient outcomes (Mullahy, 2014).

As aforementioned, the VA programs are severely constrained due to inadequate  information to support informed and appropriate care  to a current diverse cohort of patients.  The VA Utilization Management program  should be transparent enough to ensure that the health providers and service users reach their decisions by eliminating contention and  improving optimized decision making processes that put into consideration patient’s preferences (Frazier, 2014).

The utilization management program should be designed to ensure that it s actionable. This implies that the plan recognizes its implication and automatically provides specific guidance  based on evidence based clinical guidelines. The plan should deliver relevant information  in real time so as to ensure that smooth quality workflow is sustained. This includes automating workflows so as to shorten the path to seek approval, providing rapid response and  lowering administrative burden in most of pthe atients, and simultaneously allowing the clinicians to focus on complex “exceptions” that truly needs their concentration and expertise (Koike, Klap, & Unatzer, 2014).

This implies that it is time to rely on  innovate technology that suit the VA health care facility missions and vision. It is important to work on these  decision support solutions so as to help the healthcare systems to provide value based care. This is process  requires  collaborative  efforts between the healthcare providers so as to make it a reality.

References (2015). Durham VA medical Center: Retrieved from

Anonymous. (2013). Does your organization have a utilization management committee? Medical Staff Briefing, 23(11), 1,3-5.

Frazier, K. (2014). Utilization Review Software: The Impact on Productivity and Structural Empowerment in Case Management Nurses in an Acute Care Setting. Gardner-Webb University.

Koike, A., Klap, R., & Unatzer, J. (2014). Utilization management in a large managed behavioral health organization. Psychiatric Services.

Mullahy, C. M. (2014). The Case Manager’s Handbook, (5thed). Burlington, MA: Jones & Bartlett Learning. Retrieved from

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