Introduction to Healthcare Quality Management Chpt 10-11

Utilization Management (UM)
Planning, organizing, directing, and controlling healthcare products in a cost-effective manner while maintaining quality of patient care and contributing to the organization’s goals
Medical necessary
Appropriate and consistent with diagnosis and, according to accepted standards of practice in the medical community, imperative to treatment to prevent the patient’s condition or the quality of the patient’s care from being adversely affected
Failure to provide appropriate or necessary services, or provision of an inadequate quantity or lower level of service than that required
Provision of healthcare services that do not benefit the patient and are not clearly indicated or are provided in excessive amounts or in an unnecessary setting
Use of medical services and supplies, commonly examined in terms of patterns or rates of use of a single service or type of service, such as hospital care, physician visits, and prescription drugs
Utilization review
Process for monitoring and evaluating the use, delivery, and cost-effectiveness of healthcare services
Pay-for-performance systems
Performance-based payment and arrangements that control costs directly or indirectly by motivating providers to improve quality and reduce inappropriate utilization
Prospective review
A method of determining medical necessity and appropriateness of services before the services are rendered
Concurrent review
An assessment of patient care services that is completed while those services are being delivered to ensure appropriate care, treatment, and level of care
Retrospective review
A method of determining medical necessity and appropriateness of services that have already been rendered
Preadmission certification
Review of the need for medical care or services (e.g., inpatient admission, nursing home admission) that is completed before the care of services are provided
Physician advisor
A practicing physician who supports utilization review activities by evaluating appropriateness of admissions and continued stays, judging the efficiency of services in terms of level of care and place of service, and seeking appropriate care alternatives
Clinical paths
Descriptions of key patient care interventions for a condition, including diagnostic tests, medications, and consultations, which, if completed as described, are expected to produce desired outcomes
formal outlines of care; treatment plans
Discharge planning
Evaluation of patients’ medical and psychosocial needs for the purpose of determining the type of care they will need after discharge from a healthcare facility
Case managers
Experienced healthcare professionals (e.g., doctors, nurses, social workers) who work with patients, providers, and insurers to coordinate medically necessary and appropriate healthcare services
Governing body
The individuals, group, or agency with ultimate legal authority and responsibility for the overall operation of the organization; often called the board of trustees, board of governors, or board of directors
Quality management system
A set of interrelated or interacting elements that organizations use to direct and control the implementation of quality policies and achieve quality objectives
Quality management plan
A formal document that describes the organization’s quality management system in terms of organizational structure, responsibilities of management and staff, lines of authority, and required interfaces for those planning, implementing and assessing quality activities
High-performing healthcare organizations
An organization that is committed to success and continuously produces outstanding results and high levels of customer satisfaction
Organized medical staff
A formal organization of physicians and dentists with the delegated responsibility and authority to maintain proper standards of medical care and plan for continued betterment of that care
Risk management
The act of practice of dealing with risk, which includes planning for risk, assessing (identifying and analyzing) risk areas, developing risk-handling options, monitoring risks to determine how they have changed, and documenting the over all risk management program
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