Tenet Healthcare Facility Resource Management

Tenet Healthcare Facility Resource Management Order Instructions: Assignment Overview

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Utilization Review Committee – Resource Management Operations:

Tenet Healthcare Facility Resource Management
Tenet Healthcare Facility Resource Management

The value of utilization management and review has been debated among the leaders in health care since its inception. For this module’s case assignment, you are going to engage in the review of a utilization management plan for a health care organization.

Assignment Expectations

Search the Internet for a hospital or other health care organization’s utilization management plan. Once you have found one, prepare a 4- to 6-page paper. (This does not include the title or reference page) in which you address the following:
•Identify the organization you researched and include the URL for the page of the utilization management plan that you examined.
•Provide an overview of the organization’s utilization management plan- specifically, discuss each of the elements of the plan and describe how each of the elements contributes to health care quality.
•Identify two weaknesses of the organization’s utilization management plan and describe “why” you consider them to be weaknesses. Postulate ways in which the weaknesses can be overcome.

Tenet Healthcare Facility Resource Management 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 http://www.nciom.org/hmoconguide/GLOSS31E.html )

Tenet Healthcare Facility Resource Management Introduction

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.

Tenet Healthcare Facility Resource Management 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 http://books.google.com/books?hl=en&lr=&id=iUPyAAAAQBAJ&oi=fnd&pg=PA12&dq=concurrent+utilization+review+programs+in+nursing+homes&ots=iorEmkFyuh&sig=4YnmC-9Hh6jCoi0rK2dH58NhoIM#v=onepage&q&f=false

NHS England provides funding for clinical utilization review programmes to improve patient flow. (2014). Professional Services Close – Up, Retrieved from http://search.proquest.com/docview/1518167158?accountid=28844

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.

Tenet Healthcare Facility Resource Management Sample Answer


Tenet Healthcare Facility

The healthcare facility identified is  Tenet healthcare facility (see: https://www.tenethealth.com/docs/default-source/policies/policies—mn/policy—comp-rcc_4-52_utilization_management_plan.pdf?sfvrsn=4). The healthcare facility provides services to members while maximizing cost savings opportunities. 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, cystography and angiography. All the healthcare departments in this facility must follow quality assurance procedures established by its department (Tenet healthcare, 2015).

The tenet healthcare facility has a lead administrator, reporting staff and a medical director. The facility utilizes the ACO model when providing specialty care, primary care, and mental healthcare services. The facility services are evaluated using standards of administration and standards of delivery of care. The Administrative standards focus on access to quality care and patient outcomes. On the other hand, the medical standard prioritizes the facility credentials such as delivery of quality care, preventive care, and chronic diseases. Like other health care facility,  tenet healthcare facility receives a bonus based on their performance (Tenet healthcare, 2015).

Overview of organization Utilization management plan

Utilization management refers to a set of techniques applied by the healthcare administrators on behalf of health care users to benefit and manage healthcare costs through influencing care decisions based on a case-by-case assessment of the quality and appropriateness of care. The main aim of the programs is to ensure that certain services and procedures meet the appropriate clinical guidelines. The Tenet healthcare utilization management program provides reviews so as to ensure that there is appropriate care while maximizing cost saving opportunities. The functions of this utilization management plan are to ensure that the facility delivers efficient healthcare services by monitoring, evaluating and influencing health processes that impact the quality of care delivered (Anonymous, 2013).

The utilization management plan is developed by the utilization management committee (UMC) which comprises of two or more physicians, other practitioners. These include at least two doctors, one of whom is a member of the hospital medical team. The remaining committee members are from other departments within their scope of practice. The summary of the Utilization Management Plan is as shown below (Tenet healthcare, 2015);

Accessing services and making referrals:  The tenet healthcare facility provides specific policies that govern the process of pre-authorization that must be followed except in emergency care. For emergency care, the facility demands that care managers can authorize emergency services during business hours or on-call clinician during after hours.

 Initial and concurrent review: The decisions are to be made by case managers. The treatment management is initially made during the assessment. The treatment progress and continued monitoring will be done concurrently to assess the continued presence of impairments, crisis incidences, and treatment plan.

Retroactive reviews:  All the services in this healthcare facility requires pre-authorization. However, occasionally, retroactive treatment authorization will be done if necessary(during the emergency) and once authorization is received, they must be renewed by the senior care manager. In emergency treatment treated without authorization, the clinician in charge must contact care management as soon as possible.

Authorize or deny services: The standards used by this healthcare facility are based on national standards for health care services. The guidelines generally are followed to determine the level of care and treatment in each scenario. These include medication needed, the impairment functioning, severity of risk factors and level of care to treat the patient. The authorization will depend on the characteristics of the patient’s medical package.

Medical necessity and Discharge planning: The authorization of medical necessity will be determined by the patient health condition and medical cover. Discharge planning will be done following the transition assessment as soon as possible. The process will focus on patient’s preferences, goals, and needs so as to ensure that the patient gets timely and appropriate medication and discharge based on the transition evaluation. Documentations of the entire process must be completed and stored accurately  in the case management system documentation. The information recorded must be accurate and updated.

Dispute/ Appeal responsibilities: In cases of disputes, the  UM committee will work collaboratively to resolve disputes that arise and will work with National Insurance Center (NIC) and Conifer National Medicare Center (NMC).

Case management relationship: In a case where a third party is involved, the healthcare facility director of case management will work to establish as well as to maintain an effective and conducive working relationship. However, the staff must abide by the hospital information patient information privacy and security program requirements when disclosing protected information.

Information management: Utilization management data will be analyzed, collected and maintained so that to facilitate address concerns of underutilization, overutilization, and effectiveness of a resource use according to necessity and appropriate level of care, and in compliance with the federal as well as state regulations. The records will also be used for tracking the quality of care being provided.

Weaknesses of the utilization plan

 The plan does not include the human resource in the UMC. This implies that there lacks tools (information technology) as well as personnel’s to ensure that there is the efficient flow of instantaneous accurate integration of data collected into the current healthcare quality improvement program practices. (Frazier, 2014). Secondly, the utilization management plan lacks follow-up processes during adverse quality events. In addition, there is little evidence to what extent patient preferences were put into consideration when developing the health facility guidelines. This raises a concern if the utilization management committee reviews the cases based on the individual patient health demands or based on the UM  medical necessity criteria (Olaniyan, Brown,  & Williams, 2011).

The failure to integrate these two aspects in the utilization management plan can be considered as organization deficit in that the organization provides little rooms that will enable the free flow of information from patient to the entire healthcare system. This implies that it is important for quality personnel to work with managers so as to create a comprehensive framework that not only accommodates utilization management of healthcare resources but also ensures quality improvement (Tubbs,  Husby, & Jensen, 2011).

Tenet Healthcare Facility Resource Management References

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.

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

Tenet Healthcare.(2015). Utilization management Plan. Retrieved from https://www.tenethealth.com/docs/default-source/policies/policies—mn/policy—comp-rcc_4-52_utilization_management_plan.pdf?sfvrsn=4).

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

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