A CMS (§482.30) CoP requirement that helps hospitals evolve practice patterns – the Hospital Utilization Management Committee (UMC).
CoP §482.30 is not often cited as a finding in regulatory surveys – the requirements are straightforward. However, there is some level of vulnerability if the UMC does not meet the minimum standard. The real value is in the opportunity to engage physicians in providing timely, evidence-based care, in the right setting. This value is substantial and can be shared by everyone involved.
A well-functioning UMC can help change the way your organization utilizes resources. The UMC provides an outlet to examine important utilization issues, such as length of stay, location of services, and even use of testing like MRIs, ultrasounds, and other routinely ordered tests. Ultimately the goal of the UMC is to reduce the use of services that are not necessary to the care of the patient and promote efficient use of healthcare resources. Fundamentally, we are talking about eliminating waste – wasted services and wasted time. Providing the right service, at the right place, and the right time benefits everyone in healthcare, especially the patient.
Providing the Right Service
Providing the right service–ordering the right tests or treatments–are what we expect from our physicians. Providing the right service presumes the physician is using the most recent research to inform the treatment plan. Practicing based on current research or evidence sounds simple and makes common sense, but in reality, changing individual practice patterns does not come easily to most practitioners. Acting based on past knowledge or through an ingrained, perceived efficient habit is a natural human response. The challenge for physicians becomes keeping up with new research, technology, and practice, then finding the motivation to evolve to new methods. Managing the electronic health record and standing orders may even compete with the ‘right care at the right time’ philosophy. Not only can the UMC be a conduit to the most current knowledge and expertise, it can provide a framework for analyzing the current state and providing feedback to physicians about their performance.
Providing Service at the Right Location
The right location should be the service area that meets, but does not exceed, the level of care that the patient needs. Too much capability is often associated with unnecessary cost and often unnecessary risk. More is not better in this case. Keeping a patient in the ICU additional day(s) for monitoring after the patient has stabilized, for example, increases risk of infection and potentially prolongs recovery. Completing routine outpatient testing unrelated to the inpatient stay, extends the stay and will not be reimbursed. While it may be convenient, the resources are provided at a higher level of care than is needed.
As consumers are demanding more from their providers, the UMC must balance the need to improve patient experience with a way to pause and plan the care strategy for the patient and their condition. This likely will involve a conversation about the elements of the plan that can and should be done at a different location. Helping physicians with practical tools, like options for outpatient testing sites, and resources to help schedule these tests, can build the physician’s confidence that the patient will receive the follow up tests or care, and provides the patient with confidence that they are receiving a plan of care that works for them. The CoP specifically states that convenience should never be a factor in hospitalization. All parties lose in these situations because the patient stays longer in a risky environment, the hospital is not paid for the additional services, and the provider’s quality scores may be unfavorably impacted.
Providing the Right Service, at the Right Location, at the Right Time
Patients and providers do not benefit from waiting for tests or treatment, especially when the test or treatment is not essential to their care. Turn-around time is a form of waste that exists in all routine testing and treatment. When typical operating issues like staffing, equipment failure, or scheduling backlogs extend turn-around time, routine delays can extend into extra hospital days that could have been prevented. By providing regular data and feedback to providers, the UMC can help identify over-utilization of testing resources, cases with higher levels of care than necessary, and opportunities for improved workflows.
Organizations will also want to consider the appropriate metrics when creating or improving a UMC. At the highest level, evaluating length of stay and the days associated with unnecessary hospital days provide a barometer of the extent of opportunity. To get information that is actionable, however, more detailed, case-specific data will need to be examined. The medical staff are generally more comfortable dealing with individual assessments rather than looking at statistics, which sometimes raise more questions than answers. The case level review is the territory where medical staff can engage to review the medical record and problem solve. It is at the case level where specific changes in individual physician performance, changes in specific resource utilization, and changes in cost for specific diagnosis-related groups (DRGs) or DRG clusters can be identified.
Optimizing Your UMC
Reducing waste from your organization using the UMC is a strategy that can net benefits for patients, physicians, and the hospital. How can your organization get impactful results from your UMC? Consider creating a UMC structure that is physician owned and physician involved, to help change the way care is provided and set your UMC apart. Consider engaging your organizational development partners to hold a couple of insight sessions to understand any gaps in physician knowledge about resources available to them, how to hold difficult conversations with patients/families that want to “just get the test done here” and provide safe spaces for them to practice new ways of working.
Physicians are trained to use their professional judgement and scientific acumen to support and evaluate peers and their practice. Harnessing a peer-review type operating model for the UMC can drive the type of change that is needed to keep treatment protocols current and effective. For most organizations, there is a missed opportunity to actively involve the UMC. They know, for example, that their length of stay is up, but they are not using this type of resource to craft solutions. Do you have a length of stay longer than expected? Is your UMC bending practice patterns and leading adoption of change based on the newest evidence?
TiER1 Healthcare Can Help.
TiER1 Healthcare can help you unleash the potential in your healthcare team. Contact us at (800) 241-0142 or healthcare@web-archive-2025.tier1performance.com for consultation.
