Most Health Care Organizations Address Patient Safety Only Indirectly

Assessment of utilization management programs' capabilities to identify and address patient safety problems

From 2002 to 2003, research staff at URAC studied utilization management companies to learn how they use utilization management technology and processes to identify and manage potential patient safety problems.

Utilization management, a technique widely used in the health care industry to evaluate the necessity of medical interventions, has the potential to contribute to patient safety but has not been routinely used for this purpose.

URAC is a national organization that develops standards for and accredits or certifies non-HMO health care organizations, including preferred provider organizations and self-insured plans managed by employers or third party administrators.

Key Findings

Key findings from an article in Managed Care Quarterly and a report, Patient Safety Capabilities of Utilization Management Programs, include:

  • The majority of companies interviewed address patient safety indirectly, as part of general quality management.
  • Utilization management programs are primarily designed to identify potential over-use of selected services; their approach to identifying misuse or under-use of recommended services is less systematic.
  • Many of the interviewed companies have automated protocols that trigger additional case review (e.g., a request for an extended length of stay, unexpected mortality or unexpected transfer to higher intensity care).

Key Recommendations

Industry leaders interviewed in the project called for additional research to support a direct role for utilization management in promoting patient safety. Once a clear role has been established, strategies that could be adopted to support a patient safety agenda for utilization management include:

  • Creating a culture of safety by:
    • Enhancing patient safety-related policies, procedures and training.
    • Including patient-safety criteria in clinical review standards.
    • Partnering with training and educational organizations.
  • Matching patients' health care needs with appropriate services by using guidelines for hospital referrals, case management and other services.
  • Enhancing information technology systems to support decision-making and communications.
  • Identifying high-priority clinical conditions and situations where utilization management companies can standardize assessment and data collection.

Funding

The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $49,988.

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