Utilization Review And Quality Management Assignment

Utilisation Review and Quality Management
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Utilisation Review and Quality Management
The aim of the utilization review and quality management is to determine the appropriateness of the health care services provided. It does this by the laws enacted by the states and the federal regulations, statutes and all written law governing medical services (Telligen Healthcare Provider, 2014). Utilization review is then an evaluation done with the aim of determining the effectiveness of the medical procedures and facility provided under the hospital missions and objectives (Sundran & Tuminaro, n.d.). It begins the moment a patient is discharged as the review looks at the steps followed from the admission to the release time. The aim of the process is to define the professionalism of employees and compliance with the law. Quality management involves the whole strategy employed by the administration of the hospital to ensure that health services meet the required standards. It requires allocation of resources to ensure service delivery commensurate the objective and policy of the healthcare provider (Heyde, n.d). The quality management seeks to create a positive image of the hospital.
The comparison between the utilization review and the quality control is that utilization review aims at how the services at the hospital run, and if it meets the requirement of the laws and the healthcare policy. Quality management, on the other hand, deals more with the image of the healthcare provider. The focus does not only involve the patients but extends to the entire public to create a picture of a responsible institution that operates within the law and the policy guidelines. In other words, the utilization review seeks to determine how the available resources used in offering healthcare services as quality management provides more resources to improve the healthcare of an institution.
Utilization review and the quality management date back in the 1980s in America where the first criteria used in determining the condition of the health care was “as the length of stay table,” it involves analyzing data from large hospitals on the duration a patient takes during diagnosis. With time, the hospital improves on certain aspects such as reducing the time a patient takes in the hospital (Chaiken, 1996). The healthcare later developed “severity of illness criteria,” which attempted to assess the severity of particular diseases and the need to have special care like intensive care units and referral services. The other development in criteria determining the effectiveness of healthcare was the appropriateness protocol in the late 1980s; it provided rules that gov...