The role of quality assessment in the utilization management process.

Description

Hospital Cesarean Section Review

Scenario:

The hospital’s Utilization Management Committee discovers that the rate of Cesarean section births at the hospital is higher than the rate at other hospitals in the region, meaning a higher percentage of women at other hospitals are having vaginal deliveries.

The Utilization Management Committee wants to evaluate the medical necessity of Cesarean section births at the hospital using clinical practice guidelines available on this topic.

Address the following issues and questions:

1. How would you organize a project team or project improvement team to review this information?

• What steps are involved?
• Who are possible members of the review or project?
• What are their individual roles and responsibilities as members of the project?

2. What kind of data should be reviewed?

• Where would you find comparative or benchmarking data?
• Provide examples of possible data resources and examples of benchmarking information for Cesarean Section rates.

3. What are the resources available for practice guidelines?

• Provide examples of sources for practice guidelines.
• What kind of indicators (measurements) should be developed or be utilized?

4. What performance improvement tools or processes would you utilize to accomplish steps 1-3 and project goals.

5. Provide a summary of the Performance Improvement project per the accomplished steps as outlined above.