Health care management plan
Sparks Health System is a hospital based in Arkansas, pirating since 1887. It is a hospital committed to prioritizing the well-being of its patients by making use of modern technology, applying deep research into the clinical field and having informed healthcare policies. The hospital has a utilization review committee entitled with the task of coming up with procedures which guide the process of necessary medical admissions, determining whether the situation is suitable or whether a prolonged stay in the hospital for a patient is justified and whether it is necessary to provide a patient with professional services. (Sparks Health System, 2016). Efficiency is a significant factor in provision of excellent health care and financial prosperity of any facility providing acute healthcare. The utilization management plan for Sparks Health Systems can be found through the URL: https://www.youtube.com/watch?v=6vpUB6HCnrM.
In line with the Medicare Conditions of Participation Section 482.3 that requires hospitals to have a utilized review plan and a utilized review committee, Sparks Health System has a committee made up of at least two physicians, one of whom has to be a physician adviser, chief nursing officer, chief finance officer, the resource management director and representatives from subsidiary departments of the hospital whose decisions may be necessary for an informed decision-making process. Any physician with a direct financial affiliation to the hospital or is providing professional care to the concerned patient is not allowed to be part of the review committee. Such conditions are aimed at ensuring efficient and effective clinical and financial results. This composition helps in ensuring that decisions made by the committee are free of any bias and are strictly made for the benefit of the patient. It eliminates the likelihood of making decisions affected by emotional connection for the physician providing care to the patient or those influenced by selfish motives in the case of a physician with financial interest to the hospital. It removes any bias that may otherwise determine the outcome of the review.
The utilization review committee at Sparks Health Systems usually holds meetings. These meetings usually begin with following up on what was discussed in the previous meetings and confirming its minutes. This helps in finding out what has been accomplished since the last meeting, aids in keeping the concerned individuals accountable and confirms that what has been documented is correct. It also helps in determining what has been achieved and what is pending since the last meeting. This helps in the betterment of health care in that it ensures that motions passed by the review committee regarding particular patients have been acted upon and implemented. It is in these sittings that any proposals are brought forward and presented to the committee for discussion and consideration. This helps in making and upholding important decisions that affect the quality of health care as a team as it allows the exchange of ideas and deliberation on a given issue instead of as individuals which would raise the chances of bias and misinformed conclusions.
The utilization review committee is responsible for the facilitation of accountability for planned actions with regard to the identified trends. These actions are then used to prove to the joint commission surveyors and CMS Surveyors that there are mechanisms in place to identify any deviations that may be occurring in the activities of the hospital; to schedule and implement actions and to act on cases of underutilization of services and facilities within the hospital.
It is also important that level care assignment is addressed properly and correctly and is done prospectively, concurrently, retrospectively and through the use of certified methods. Prospective review is used to check whether an application is viable or justifiable hence helps to avoid admission of undeserving cases. This process ensures that only the truly deserving cases pass through hence reducing congestion and ensuring that priority is given to those that deserve the services. (1 - Prospective Review Procedure, 2016).
Concurrent review involves a clear and thorough review during the patient’s duration of stay in the hospital as per the hospital’s UR plan. It helps in reducing the number of patients denied services at the medical facility as well as recommending the patients to the most appropriate point of care. It is important in that it helps to ensure that there are no deserving cases that have been denied attention at the prospective review stage.
Retrospective review entails a review of familiar cases with suitable solutions as per the hospital’s UR plan, compliance work plan or other UR committee directed reviews and recommendations. It weighs the appropriateness of the degree of care being provided for a certain case in terms of the time, the location and the procedure being followed. It is guided by the kind of insurance plan available to the patient. This is important for the quality of health care in that it ensures that the patient is accorded a level of care that they can afford to pay for. This in turn helps the health facility to maintain a healthy financial status enabling it to run its activities hence provide care to more patients. (Utilization Review Committee - Resource Management Operations, 2016).
Certified and approved methods of review entails compilation of trends by the physician in charge, time of admission or other categories as may be deemed appropriate. These steps of review ensure that the important details are put into consideration and clearly analyzed and any past information that may be crucial to the situation is looked at carefully to ensure that the decisions made by the committee are the most suitable for that particular situation.
The findings of the Utilization Review Committee are then sent to the MEC and the governing board at each facility where the medical staff make the necessary interventions and follow ups. This step is important as it facilitates the execution of the findings of the review committee which would be irrelevant were they to not be put into action as recommended. It ensures that the patient is treated as per the findings of the review committee hence appropriate treatment is administered.
However, Sparks Health System utilization management plan has its weakness. It handles the financial aspects of provision of health care as a determinant to the overall outcome of the treatment process. This is seen as a misplaced priority as it ranks the process of care together with the outcome of care. This can be solved by having a plan that distinguishes and realizes that the two processes are independent and the finances spent in the care process do not necessarily reflect the outcome of the treatment process.
The utilization review also puts emphasis on reducing the burden of cost on insurers thereby running the risk of patients being denied medical services in cases where the cost of their treatment exceeds the threshold set by the insurers. The management plan may need to be changed in such a way as to allow patients the liberty to be treated without the limitations of their insurance cover.
References
Sparks Health System. (2016). Sparkshealth.com. Retrieved 25 April 2016, from http://www.sparkshealth.com
1 - Prospective Review Procedure. (2016). Labor and Workforce Development. Retrieved 25 April 2016, from http://www.mass.gov/lwd/workers-compensation/med-providers/ohp/ur-procedures/prospective-review.html
Tischler, G. L. (1990). Utilization Management and the Quality of Care. Psychiatric Services, 41(10), 1099-1102.
Utilization Review Committee - Resource Management Operations:. (2016). YouTube. Retrieved 25 April 2016, from https://www.youtube.com/watch?v=6vpUB6HCnrM
