When Fredonia (KS) Regional Hospital looked into updating its utilization review program, it focused on two key areas: involving the right people and being aware of its communication with the medical staff and its bylaws.
The goal of the program was to ensure that hospital resources were being allocated appropriately with the goals of maintaining quality patient care; achieving the best possible efficiency of hospital resources; promoting quality of care through the right level of analysis, review, and evaluation of clinical practices; and, of course, ensuring that the care being provided was medically necessary and appropriate.
"We had an existing utilization review policy, and it wasn't very effective," says Pam Harmon, RN, LNC, chief nursing officer at Fredonia. "We needed to be more diligent."
What they needed, she and her colleagues realized, was an active committee to help get the medical staff aligned with the most up-to-date utilization policy.
But first things first: involving the right people. As a starting point, Harmon reached out to the record review committee. The team also sought feedback from the organization's utilization review nurse.
Billers and coders were equally represented.
"I was previously unaware of the separateness of those two roles," says Harmon. "The billers, coders, business office, and medical records office all have specific jobs which, while we might think of them together, are completely separate in their minds. We needed to go beyond inviting just someone from the business office and medical records."
They also invited a social worker to the committee.
"She has so much to do with people being compliant in finding the right services," says Harmon.
The team was rounded out by the discharge planner. Additionally, Harmon suggests including the corporate compliance officer on the committee.