Managed Care - October 2008 - (Page 28) patient experiencing an ST-segment elevation myocardial infarction (STEMI) arrives at the emergency room door, or from when the incident was called in by the ambulance, until he or she is actually on the table getting a balloon angioplasty. In these examples, reducing transition times improves efficiency but also has the potential to improve quality. A door-to-balloon time of 90 minutes or less makes good outcomes significantly more likely and can save lives. Reducing an ED backlog means that incoming patients can be seen more quickly. The Institute for Healthcare Improvement cites improving patient flow as an activity that “increases patient safety, positively impacts patient and staff satisfaction, and increases revenue.” During contract negotiations, hospitals, health plans, and other payers can evaluate the availability and use such programs as they relate to desired outcomes for improved efficiency and quality. Field feedback When utilization management staff members were interviewed about their perceived and actual roles in quality improvement for both hospitals and health plans, they consistently acknowledged missing opportunities to improve quality and voiced a desire to be part of an effort for improving quality. Some organizations are more progressive in their integration or approach to these issues than others, and the utilization management staffers identified several projects related to quality in which they participate, including efforts to reduce readmissions and to identify and prevent “never events.” These UM staff members identified several barriers, including: • Lack of support or recognition from leaders of their organization for their involvement in quality improvement as an opportunity or priority • Lack of support from clinical floor staffers for these efforts • Organizational structures that do not facilitate interdepartmental communication • Lack of human resources (time and personnel) and tools (information technology and systems) to allow efficient, instantaneous, and accurate identification, collection, and aggregation of data • Lack of follow-up processes when potentially adverse quality events are identified Conversely, the staff members identified a number of opportunities to remove these barriers: • Acknowledging information/data collected by the utilization management staff as potentially important indicators of quality • Creating an action plan for quality improvement that involves the utilization management staff • Collecting nonclinical and related operational variance data to identify omissions and delays in care that may signal quality problems • Identifying opportunities for improvement through discussions among the staff of the utilization management, quality, and provider or payer relations departments and develop- Don’t underestimate value of utilization managers roper use of utilization managers can greatly increase hospital efficiency. These professionals, typically licensed and experienced RNs (social workers and others may be included), are charged with verifying and documenting medical necessity for hospital admissions and continuation of inpatient stay for commercial payers (insurers, third-party administrators, and managed care organizations) and the big payer, the Centers for Medicare & Medicaid Services. In some facilities, the utilization/case management role may expand to include patient education and discharge planning. From an investment perspective, a 150-bed hospital spends around $500,000 annually in salary and benefits for these workers, depending on variables such as staffing ratios, geography, and job descriptions. Yet despite investment in these staff positions and the simultaneous pursuit of many quality improvement initiatives, the utilization management role continues to be only weakly associated with the rights, ability, and responsibility to contribute to quality improvement initiatives. P 28 MANAGED CARE / OCTOBER 2008
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