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Fam Pract Manag. 1998 Nov-Dec;5(10):11.

Utilization management

Q

I am the sole physician on a committee tasked to revamp utilization management (UM) at our hospital. I'm having trouble getting the administration to understand that UM is a way of taking care of patients, not just a way to do business. They're trying to set up a UM hierarchy that has virtually no clinical input or guidance. Any suggestions?

I have been the chairman of our hospital UM committee for the past four years and have lived through the same type of transition. It involves moving from a utilization review process based only on costs to a total UM program that is geared to improving value by ensuring that the care provided is of the highest quality and the lowest possible cost. The most important thing to remember is that the entire UM program must be an outgrowth of the medical staff governance process and must therefore be driven by clinical input.

Since hospital managers tend to focus on “bean counting,” a good way to enlighten them might be to set up a program that presents the clinical aspects of utilization in terms of beans they can count — a “best clinical practices” program for the entire medical staff. You could use the hospital's extensive database on resource usage and clinical outcomes to publish quarterly reports of statistics for all physicians based on comparisons with their peers.

These statistics would be inclusive of both cost factors and outcomes data. A system such as this accomplishes several things: It includes significant clinical input, cost data and quality data, and, most important, it brings peer review to the UM process.

At our hospital, a program such as this has resulted in decreased resource usage and increased quality outcomes.

Creating an office manual for rural health certification

Q

Our practice will be inspected for rural health certification soon. We have to develop an office policies and procedures manual. What needs to be included in the manual?

The 1977 Rural Health Clinics Services Act requires a manual to be in place before a rural health clinic can be certified. The table of contents must include specific subjects, but the information within each section may vary depending on state and local policies. The following table of contents can be used as a model:

  • OSHA manual and annual staff training documentation.

  • Biohazard waste manual. If your state requires this manual, you should note the location of the waste in the building and who disposes of it.

  • Organizational chart of the practice. This chart will show the practice's line of authority and organization.

  • Safekeeping and disposal of drugs. Indicate where pharmaceuticals are kept and your precautions against theft, how often the drugs' expiration dates are checked and who checks them, and what is done with outdated materials.

  • Emergency procedures and training. This section will explain how to handle phone emergencies and medical emergencies in the office.

  • Delineation of responsibilities for midlevel providers (MLPs). Create a check-off list of procedures that MLPs can perform. It should be signed and dated by MLPs and physicians.

  • Medical records policies and confidentiality statements.

  • Personnel policies. These should cover equal opportunity employment, sexual harassment, employee benefits, telephone usage, sick and vacation leave, etc.

  • Job descriptions.

  • Patient insurance filing guidelines and billing and collections procedures.

Copy the licenses of all licensed personnel and place copies in the manual for quick reference.

Many consultants and publishing companies have prototype manuals that you can customize to your practice.


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Copyright © 1998 by the American Academy of Family Physicians.
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