nating Committee and the individual hospital utilization committees. A Utilization Committee will be established within the medical staff of each hospital to assure that the in-patient service given is necessary and could not be provided as effectively in the home, office, hospital out-patient department or some other more appropriate, available facility. The committee shall analyze and identify factors that may contribute to unneces sary or inefficient use of in-patient services and facilities and make recommendations designed to minimize ineffective utilization. NOTE: SEE ORGANIZATION CHART, PAGE 5 The following sections 3, 4 and 5 contain de tailed information on the operation of the program: 3. Hospital Utilization Committees Unnecessary admissions. Excessive length of in-patient stay. Delay in use or over-use of x-ray, laboratory and In each of these categories, the Utilization Committee provides answers to such questions as the following: How many of such cases are there? What factors contribute to these conditions? What practical recommendations can be made to the medical staff, chiefs of clinical and non-clinical services, administration, prepayment plans and to the community to avoid these situations? A. Organizing The Utilization Committee 1. Appointment of Members Appointment of the chairman and Committee members should be made by the President of the Medical Board in accordance with existing bylaws governing the organization of medical staff committees. Generally, appointments should be for a three year period; one-third of the committee should be rotated each year. Reappointments may be made after a lapse of one year. 2. Size of the Committee The actual number of members of the Committee will be influenced by the size and or ganization of the medical staff and the number of hospital admissions. For effective functioning, however, the Committee should usually number no less than five. 3. Composition of the Committee Membership on the Committee should include either the chief or a representative of each major department. It seems advisable that the departments of pathology, radiology and anesthesiology be represented on the Committee. The hospital administrator, or his designated assistant, should attend the meetings. The administrator should be responsible for the minutes of the meeting and for furnishing information on administrative procedures and policies which the Committee may request. Members of the medical staff who are not on the Utilization Committee may be invited to serve temporarily on the Committee when specific areas of study are selected in which they have special competence. The chief resident, the medical record librarian, the chief social worker and other hospital department heads should sit in at meetings, on invitation from the Committee. 4. Meetings The Utilization Committee should meet as a group once a month to conduct its activities. More frequent meetings may be held if deemed necessary by the chairman. Review of cases and records will be done by Committee members prior to the regular meeting. Presentations of findings should then be made to the full Committee for discussion and disposition. If the size of the medical staff and the extent of its organization warrant, the Utilization Committee may be divided into medical and surgical sub-committeess which will be concerned with cases relating to their respective services. Such sub-committees may meet independently for initial case review; however, analyses and findings should always be presented before the full Utilization Committee for review and recommendations. B. Relationships 1. With Chiefs of Service The Committee will need to maintain liaison with the chiefs of service for referral of particular situations indicating questionable or inappropriate utilization. 2. With Other Committees of the Medical Staff The Utilization Committee should work closely with other medical staff committees, seeking their assistance when indicated. (a) Medical Record Committee The work of the Utilization Committee is largely dependent upon the availabil ity in the hospital of up-to-date charts which contain sufficient information to justify the decisions made by the attending physician in charge of the case and to permit objective review. The analyses of the Utilization Committee may point up inadequacies in the charts not revealed by review from the standpoint of accrediting bodies, legal requirements or quality control. Recommendations for improvement of medical records, including possible revision of forms, should be referred to the Medical Record Committee for appropriate action. In conjunction with its work, the Utilization Committee may wish to recommend various changes in forms and record procedures to the Medical Record Committee. (b) Tissue Committee In general, the Utilization Committee will need to maintain closest liaison with the Tissue Committee which is responsible for establishing the justification for surgery done in the hospital. The chairman of the Tissue Committee should have a standing invitation to attend meetings of the Utilization Committee. (c) Operating Room, Admissions, Pharmacy and Other Medical Staff Committees Many of the recommendations of the Utilization Committee will be referred to the Operating Room, Admissions, Pharmacy and other medical staff committees for review and action, thus requiring liaison with them. C. Functioning of the Utilization Committee 1. Review of Charts In general, the Committee will function by reviewing and evaluating charts of discharged in-patients. The Utilization Committee may also concentrate on daily screening of cases admitted to the hospital. It must be recog nized, however, that information available at the time of admission is sometimes insufficient for objective evaluation of the need for hospitalization. In addition, this approach does not consider the problem of excessive length of stay. For these reasons, it is desirable that the Utilization Committee devote its major efforts to consideration of completed charts of discharged in-patients. It is obviously not possible or even desirable for the Committee to examine the chart of each in-patient. The work-load should be divided among the Committee members and the review should be based upon selection in advance of the most appropriate categories of cases. Each member of the Committee should be assigned responsibility for reviewing charts in advance of each meeting and should be prepared to discuss those charts which raise specific questions. To the extent possible, each committee member should review those types of cases in which his judgment would be best, based on experience and training. 2. Classes of Charts to be Reviewed The Committee will function most effectively if it limits its studies to specific problems and specific types of cases. The following categories of cases may be selected for review at different times: (a) Long-stay Cases At first, every case which remains over 15 days should be studied. As progress is made, the period of stay for cases to be studied may be shortened. Currently hospitalized cases as well as those previously discharged are suitable for review. (b) Short-stay Cases About 10 per cent of all cases admitted to general hospitals are discharged after one day. Included among these cases may be a significant number admitted for diagnosis or other procedures which might have been provided as effectively without admission. Each short-term case where the need for admission is questionable should be reviewed. (c) Cases Questioned or Rejected for Payment by Prepayment or Insurance Plans Prepayment and insurance plans complaints involving questionable use of hospital facilities or services may be directed to the Nassau County Medical Society Coordinating Committee for review. Review of such cases may provide a basis for development of better understanding with such plans, improvement of their procedures and better service by physicians to the insured public. (d) Cases in a Specific Diagnostic or Opertive Category Usually, the work of the Committee will be carried out by study of all of the recently discharged cases with a specific diagnosis or operation. A different diagnosis or operation can be studied each month. Special attention should be given to identifying the different characteristics, if any, of the patients with the same diagnosis who had the longest stays in comparison with those who had the shortest stays. 3. Use of Check-list or Review Form A check-list or review form should be used by members of the Utilization Committee in reviewing charts. The administrator and medical record librarian should assist in designing a general form. Special forms may be designed for use in studying specific classes of cases. Suggested check-lists are attached as Exhibits I and II. The first form is completed by the medical record librarian. The second form, which is completed by the member of the Utilization Committee, reflects the opinion of the reviewing physician and includes a number of items to be marked "yes" or "no," with space for detailed explanation where indicated. The reverse side of the form is to be used for recording any action to be taken by the Utilization Committee, together with recommendations made and the final disposition. To keep the records confidential, the patient should be identified by hospital number only, while the names of the attending physician (s) and member (s) of the Utilization Committee reviewing the record should be in code. Initially, it is advisable to become familiar with the various questions and explanatory comments on the check list and thus gain a general understanding of the points covered. The check-list can be completed most rapidly if the medical record is reviewed first in its entirety and management of the case studied. 4. Obtaining Additional Information from the Attending Physician In some instances, the Committee member reviewing the chart may feel a need for additional information. Discussion with the attending physician should be encouraged in such circumstances. The Committee should develop a general policy on the conditions under which these consultations are held. In some instances, the attending physician may be requested to meet with the Utilization Committee in order to provide additional information. 5. Records The Utilization Committee should maintain adequate summary records of its activities. In general, these summaries can be developed from the data recorded by the Committee members on the check-list forms and should be incorporated as part of the Committee min utes. Summary records should include the total number of charts reviewed by appropriate category and identified by case number, the number of charts in which a question was raised concerning unnecessary utilization and the disposition of cases reviewed. All records of the Utilization Committee, including the check list, should be kept confidential and be available only to the Medical Board. The check-list should not be filed with the medical record. 6. Follow-up and Recommendations Whenever the Utilization Committee's analyses reveal any possible evidences of unnecessary utilization, the Committee should consider possible avenues of correction. In general, this will take the form of a recommendation that the appropriate medical staff committee, chief of service or member of the administrative staff explore the problem and report the disposition of the matter back to the Utilization Committee for its information and records. For example, recommendations directed to administration might involve analysis of cases indicating need to: Institute methods to overcome delays in transmitting orders and carrying our various diagnostic and therapeutic proced ures. Overcome inadequate week-end and night coverage. Strengthen social service. |