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Module Introduction

You read and discussed the term quality management . Utilization Management is a component of quality management that was operationalized in the early 1980s by the American Heart Association with a goal to provide continuity of care, coordination of services and improved health outcomes, while increasing the effectiveness and efficiency of services provided to Members (patients). The appropriateness of healthcare service is based on scientific knowledge.

The National Committee for Quality Assurance (NCQA) provides a framework for implementing industry best practices to ensure:

Fair and timely utilization evaluations using objective, evidence-based criteria:
- Collection and use of relevant clinical information to make utilization management decisions.
- Qualified health professionals assess requests and make utilization management decisions.
Alignment with state requirements. (NCQA, n.d.)

NCQA. (n.d.) A quality improvement framework. Retrieved August 13, 2020 from https://www.ncqa.org/programs/health- plans/utilization-management

In Chapter 11 and 12, Spath (2018) reminds us that frontline caregivers are not alone is making sure our patients receive quality care. There are others in the healthcare organization who examine healthcare quality. You will explore your own organization's quality management framework for creating an environment that is recognizes the critical nature of quality management and focuses on healthcare improvement. There are several groups that are responsible for quality management - beginning at the Board level, Administration, a performance improvement committee (may also be named quality council, quality or patient safety committee etc.), medical staff , various departments, quality support services including quality director, case managers or utilization reviewers, patient advocates, risk manager, patient safety coordinator, physician quality advisor, infections control coordinator etc. You may recognize these titles and those personnel who fill those rolls. Many are nurses who maybe you!

A quality management plan is developed and serves as a "blueprint". Review the several Exhibits and Critical Concepts in this chapter as they are explanatory and provide additional context to quality management.

Learning Outcomes

Describe the purpose of Utilization management
Consider the cultural assumptions and beliefs underlying a perfectionist mentality: Perfection is always expected; mistakes aren’t allowed.

Course Materials

Readings

Required Reading

Chapters 10 & 12 in Spath, P.L. (2018) Introduction to Healthcare Quality, 3rd Ed. Health Administration Press: Chicago, IL.

Suggested Readings

The Risks and Rewards of Value-Based Reimbursement_2015.pdf

Increasing Global Awareness of time COVID-19 Healthcare Guidelines...2020.pdf

Improvement in Orgs. Cultures of Health Reduces Workers Health Risk Provide and Health Care Utilization.pdf