Introduction to Quality Assurance
The Utilization Management Program of the Naval Hospital Guam facility is one which is designed to ensure that high quality, cost efficient health care is delivered to all members of the community. The Utilization Management Division is responsible for implementing a Utilization Management Plan which will monitor the appropriate usage of the health care facilities, services and its resources. These services may include utilization reviews, case management, discharge planning and outcome-based evaluations. The Utilization Management Program is completely planned and put into action by this division. It is also responsible for coordinating and monitoring access to care, developing programs, and evaluating the quality of healthcare services in accordance with guidelines from the Department of Defense, Lead Agent, Regional 12, and Health Affairs.
UTILIZATION MANAGEMENT PROGRAM
The following provides an overview of the various functions of the Utilization Management Program at the Naval Hospital Guam facility. The program requirements may vary based on the member.
Specialist Referrals– The Primary Care Physician (PCP) may request a consultation from a participating specialist physician at any time. The PCP determines the number of visits authorized. Specialists may include – Gynecologist, Radiation Oncologists, Ophthalmologists, Pediatric Ophthalmologists, Retinologists and Allergists etc.
Emergency Room Services –An emergency medical condition is defined as a condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention ...
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...d over-utilization) and ensure the efficient scheduling of resources.
• Assure fair and consistent utilization management decision-making.
• Timely resolution of identified problems.
• Promotion and maintenance of optimally achievable quality of care.
• Education of medical providers and other health care professionals on the appropriate and cost-effective use of health care resources.
WORKS CITED
Naval Medical Center San Diego 2008. NMCSD. Patient Services Retrieved May 5, 2008 from
http://www-nmcsd.med.navy.mil/
Utilization Management 2008. Prospective, Concurrent and Retrospective Review Retrieved May 5, 2008 from
http://www.paramounthealthcare.com/body.cfm?id=67
U.S. Naval Hospital Guam 2006. Directorate for Healthcare Management. Quality Management Department Retrieved May 5, 2008 from
http://www.usnhguam.med.navy.mil/directorates/dhm/default.htm
The challenges that all acute care hospitals and facilities faces are the demand for highly specialized services has increased. The US population is constantly aging and the elderly tend to need more acute care services. Because many people lack health insurance, they tend to use emergency rooms in the hospitals as their source of care. The increase demand in acute care prompted hospitals to expand their facility
State and federal regulations, national accreditation standards, and clinical practice standards are created, and updated regularly. In addition, to these regulations, OIG publishes a compliance work plan annually that focuses on protecting the integrity of the program, and prevention of fraud and abuse. The Office of the Inspector General examines quality‐of‐care issues in nursing facilities, organizations, community‐based settings and occurrences in which the programs may have been billed for medically unnecessary services. The Office of the Inspector General’s work plan for the fiscal year 2011 highlights five areas of investigation for acute care hospitals. Reliability of hospital-reported quality measure data, hospital readmissions, hospital admissions with conditions
Moss, A. J. et al. Design and operation of the 2010 National Survey of Residential Care Facilities. Vital Health Stat. 1. 1–131 (2011). at
Because of the lack of organization with the health care providers in Canada, the wait times are too long and can cause serious complications to any condition the patient went in for in the first place. This situation of how the health care system can resolve wait times was brought to the government but they continue to ignore the proposals brought to them. It is possible to resolve the problems of wait times without extreme change and expenses in the health care system. The solution is to be found in the reorganization of the health care providers. Lack of assistance in the emergency room can make ones illness to become worse, therefore, causes the patient to be forced to wait in emergency rooms for an extended period of time and when they are finally seen by a health care provider, the outcome is very poor due to lack of registered staff, physicians and proper assessment(Goldman & Macpherson, 2005, p.40). The objective of this paper is to discuss and critically analyze the conditions of emergency waiting rooms. The specific issue this paper intends to explore is extensive and prolonged waiting times for patients accessing health care, patients who need urgent treatment and the vulnerability of elderly patients and children. With an in-depth critique of the barriers to health care and shortcomings of emergency rooms, strategies will be provided to enhance a health care system that makes it more accessible and efficient.
For patients requiring longer acute care than what is generally given at an inpatient acute care hospital, The Long Term Acute Care Hospital is an option. To be admitted to an LTACH, patients are required to have “medically complex situations with a mean length of stay > 25 days” (Munoz-Price, 2009, p. 438 ). Examples of patients with complex acute care needs are those with multiple comorbidities who need mechanical ventilator weaning, administration of intravenous antibiotics, and those with complex wound care (Munoz-Price, 2009, p. 438). According to Landon Horton, CNO of Select Specialty Hospital in Fort Smith, Arkansas, “The services provided by LTACH facilities allow the patients to get home who would not otherwise, have a higher level of functioning at discharge, and increase their quality of life” (personal communication, March 7, 2014).
middle of paper ... ... International Journal for Quality in Healthcare, 25(3), 261-269. Retrieved from http://intqhc.oxfordjournals.org/content/25/3/261.short Smedley, B., Stith, A., & Nelson, A. (2003). The 'Secondary' of the 'Secondary'.
The Centers for Medicare and Medicaid Services (CMS) have recently begun requiring hospitals to report to the public how they are doing on patient care. Brown, Donaldson and Storer Brown (2008) introduce and explain how facilities can use quartile dashboards to transform large amounts of data into easy to read and understandable tool to be used for reporting as well as to determine areas in need of improvement. By looking at a sample dashboard for an inpatient rehab unit a greater understanding of dashboards and their benefits can be seen. The sample dashboard includes four general areas, including nurse sensitive service line/unit specific indicators, general indicators, patient satisfaction survey indicators and NDNQI data. The overall performance was found to improve over time. There were areas with greater improvement such as length of stay, than others including RN care hours and pressure ulcers. The areas of pressure ulcers and falls did worse the final quarter and can be grouped under the general heading of patient centered nursing care. The area of patient satisfaction saw a steady improvement over the first three quarters only to report the worst numbers the final quarter. A facility then takes the data gathered and uses it to form nursing plan...
Three areas that define the provisions of comprehensive health care services and are commonly used for utilization monitoring and control are gatekeeping, case management, and utilization review (UR). Gatekeeping is used by HMOs where each member designates a primary care provider (PCP) that is responsible for coordinating all care services needed for the enrollee in a managed care plan. Case management involves an experienced health care professional with knowledge of available health care resources. `Case management services are designed to identify spec...
Jencks, S., Williams, M., & Coleman, E. (2009). Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine, 1418-1428. Retrieved November 12, 2014.
Leal, S., Herrier, R.N., Glover, J.J., & Felix, A. (2004). Improving quality of care in
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensur...
Hospitals recognized the need for the case management model in the mid 1980’s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007). In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals ...
Emergency is defined as a serious situation that arises suddenly and threatens the life or welfare of a person or group of people. An emergency department (ED) or also known as emergency room (ER) is a department of a hospital concentrating in emergency medicine and is accountable for the delivery of medical and surgical care to patients arriving at the hospital needing an immediate care. Usually patients will arrive without prior appointment, either on their own or by an ambulance.
...d procedures are now being monitored to improve clinical processes. Ensuring that these processes are implemented in a timely, effective manner can also improve the quality of care given to patients. Management of the processes ensures accountability of the effectiveness of care, which, as mentioned earlier, improves outcomes. Lastly, providing reimbursements based on the quality of care and not the quantity also decreases the “wasting” and overuse of supplies. Providers previously felt the need to do more than necessary to meet a certain quota based on a quantity of supplies or other interventions used. Changing this goal can significantly decrease the cost of care due to using on the supplies necessary to provide effective, high-quality care. I look forward to this implementation of change and hope to see others encouraging an increase in high-quality healthcare.
In U.S. news best hospitals 2014-15, John Hopkins Hospital is regionally ranked number 1 in Maryland and also the Baltimore Metro areas, in addition to being ranked nationally in 15 adult and 10 children specialties. (US News & World Report LP, n.d.). The hospital opened its doors in 1889, and has been ranked number 1, 22 of the 25-year history of the U.S. News and World Report (most recently in 2013) (John Hopkins Medicine, n.d., para 3). It’s mission is to “is to improve the health of our community and the world by setting the standard of excellence in patient care” and identifying 6 aims specifically to accomplish this (John Hopkins Medicine, n.d.b, para. 1). One glimpse of the strategic plan illustrates the comprehensive framework, by which