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Utilization Management in Healthcare

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MHM505 - Introduction to Quality Assurance

Module 3 - SLP

Utilization Management

Introduction Background Information Case assignment Session Long Project Objectives

The Session Long Project for this course is to evaluate and critique a health care facility you are familiar with and compare it to the general principles and standards for quality assurance presented in this course.
In the earlier modules you identified a health care facility for the subject of the SLP and presented a description of the facility and its quality assurance program. You also critiqued the facility's Continuous Quality Improvement program.

In this module you will discuss and critique the subject facility's Utilization Management program. The remaining modules for the Session Long Project the remaining tasks are as follows:

Module IV. A discussion and critique of the subject facility's Case Management program will be presented.

Module V. Discussion of the subject facility's Risk Management program will be presented.

Module VI. This is a summary or wrap-up module. You will complete your SLP and submit it, if you have not already done so.


For this module you are to complete the following tasks:

• Describe and discuss the facility's Utilization Management program.

• Compare and critique the subject facility's Utilization Management program to that of a model facility and whether the facility adheres to the recognized standard for utilization management, including utilization review and whether this review leads to improvement in the quality of care.

• Identify areas for improvement in the facility's Utilization management program, if any and any recommendations you think should be implemented to improve the quality of patient care.

Session Long Project Assignment Expectations

Length: SLP assignments should be at least 4-5 pages in length.

References: At least two references should be included from academic sources (e.g. peer-reviewed journal articles). When material is copied verbatim from external sources, it MUST be enclosed in quotes. The references should be cited within the text and also listed at the end of the assignment in the References section (preferably in APA format).

Organization: Subheadings should be used to organize your paper according to question

Format: APA format is recommended (but not required) for this assignment. See Syllabus page for more information on APA format.

The following items will be assessed in particular:
•Relevance (e.g. all content is connected to the question)
•Precision (e.g. specific question is addressed. Statements, facts, and statistics are specific and accurate).
•Depth of discussion (e.g. present and integrate points that lead to deeper issues)
•Breadth (e.g. multiple perspectives and references, multiple issues/factors considered)
•Evidence (e.g. points are well-supported with facts, statistics and references)
•Logic (e.g. presented discussion makes sense, conclusions are logically supported by premises, statements, or factual information)
•Clarity (e.g. writing is concise, understandable, and contains sufficient detail or examples

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Solution Summary

This solution describes key aspects involved with healthcare management.

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Description of organization's utilization management program: Durham Regional Hospital's utility management program is run by the health benefits administrator within the organization, whose efforts are supplemented by the input that is provided by departmental managers within organization. In essence, the health benefits administrator seeks to statistically ascertain the level of demand for different forms of treatment that are provided within the organization, in order to develop a proactive and efficient plan by which to be able to ensure that this patient demand can be met without lowering hospital quality standards. This includes ensuring that there are adequate staff members to meet patient demand for treatment, patients are processed for treatment in expeditious manner, patient records are kept in a safe, secure areas within the hospital, staff members are highly trained in carrying out the procedures, and that discharges are carried ...

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