Well, I am not yet quiet finished on trying to tell you all about the Joint Commission International (JCI) Standard MCI.20.1. In this post I wish to share on the what, why and how about utility system management and utilisation review, the remaining two other important parts of the improvement activities of a hospital by which the hospital attempts to aggregate data to provide a profile of the hospital over time which then will allow the comparison of the hospital’s performance with other hospitals. Utility system management and utilisation review are the last of the four improvement activities of a hospital identified in the intent statement of the JCI Standard MCI.20.1.

My intent is to discuss in this post:

1. in brief about utility system management and utilisation, as this single post cannot cover all about utility system management and utilisation review; and
2. more importantly to highlight to management and hospital leaders when one is entrusted to champion the course of all the JCI Management of Communication and Information (MCI) standards, the probability when a hospital which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, is expected to present the case of a process for both utility system management and utilisation review, when surveyors examine evidence under JCI Standard MCI.20.1 ME 1 the process to aggregate data from utility system management and utilisation review at a hospital in response to identified user needs  – in order to satisfy the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”.

Before I go on, my intent (ii) above is true for aggregate data from risk management as well as for infection prevention and control as  I have posted in JCI Standard MCI.20.1, ME 1 (Part 1) – risk management, in “The organization has a process to aggregate data in response to identified user needs.” and in JCI Standard MCI.20.1, ME 1 (Part 2) – infection prevention and control, in “The organization has a process to aggregate data in response to identified user needs.” respectively (each of these links will open in a new tab of your current browser window).

Medical insurance in Malaysia, provided by insurance companies and banks which provide a few plans for anyone to choose from based on own budget and needs, functions as a form of protection to cover unforeseen expenses arising from illness, injury or accidents – which can be very expensive, especially if hospitalisation and / or surgery is required.

Malaysian readers will already be aware that insurance companies in Malaysia provide coverage plans for medical services for their clients at any hospital. Malaysian readers will also be aware that health insurance companies in Malaysia request medical reports for approval of claims to confirm that any insurance plan provides for the coverage of medical services rendered.  While this is true for Malaysia, I have never known the need for utilisation review to review a request for medical treatment in Malaysia.

Let us now assume that utilisation review by insurance companies is practised in your settings and take this discussion from there.

Utilisation review refers to reviews of past medical treatment, for example in the United States where insurance companies perform an utilisation review to review a request for medical treatment. I have below a cropped infographic which provides the anatomy of health insurance coverage in the U.S. (click the infographic which will open in a new tab of your current window for a larger view).

The purpose of the review is to confirm that the plan provides coverage for a patient’s medical services typically found on an insurance policy’s precertification list.  The utilisation review also help an insurance company minimise costs and determine if the recommended treatment is appropriate. The company could deny coverage as a result of a utilisation review.

What about care based on medical necessity in the future, for example for approval for additional treatments while you’re undergoing medical care (a concurrent review)?

Utilisation management is the process of preauthorisation for medical service as it refers to requests for approval of future medical needs, and this term is often used interchangeably with utilisation review since both utilisation review and utilisation management involve the review of care based on a medical necessity.

Thus, the term “utilization review” refers to a retrospective review – the review of treatments or services that have already been administered, and involves the review of medical records in comparison with treatment guidelines. The insurance company uses the results to approve or deny coverage a patient has already received, and the information can also be used in a review of the insurance company’s coverage guidelines and criteria for a particular condition. The insurance company looks through a patient’s medical records for evidence of appropriate low-cost health care. It then compares this patient’s medical records to those of other patients with the same condition. It will then review, and possibly revise, its treatment guidelines and criteria to ensure that the provided care is adequate, and medically current, for the condition.

Therefore, hospitals get actively drawn into the process of the collection of information, including the symptoms, diagnosis, results of any lab tests and list of required services by providing clinical documentation that supports their treatment decisions.

I think Health Information Management (HIM) / Medical Records (MR) practitioners have a clear role in utilisation review if their setting is appropriate. HIM /MR practitioners will need to be aware (i) of the existence of an utilisation review policy and the relevant processes, and (ii) to contribute to good records keeping since a high retrieval rate of medical records can be expected when patients’ medical records are examined for evidence of appropriate low-cost health care and for comparison of treatment among other patients’ medical records for a similar condition, by the insurance companies.

I think to round-up the discussion on utlisation review, it is safe to justify then if a hospital –  which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, satisfies the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”, if the hospital can provide evidence of documentation of a process to aggregate data i.e. in response to the identified user needs when data is aggregated for utilisation review.

Now, allow me to move forward to present utility system management.

Hospitals have different medical equipment and utility system needs based on their mission, patient needs, and resources. Regardless of the type of system and level of its resources, a hospital needs to protect patients and staff in emergencies, such as system failure, interruption, or contamination. The safe, effective, and efficient operation of utility and other key systems in the hospital is essential for patient, family, staff, and visitor safety and for meeting patient care needs.

The business of utility system management in a hospital is about:

1. a constant potable water and electrical power supply
   1. first identifying  the areas and services at greatest risk when power fails or water is contaminated or interrupted, secondly to reduce the risks of such events and thus ensuring an uninterrupted (24-hour basis, every day of the week) source of clean water and electrical power, and when necessary regular and alternative sources of power and water must be identified that can be sourced in emergencies
   2. emergency processes to protect hospital occupants in the event of water or electrical system disruption, contamination, or failure
   3. testing its emergency water and electrical systems on a regular basis appropriate to the system and the results documented
2. regular inspection and maintainance of electrical (example, frayed electrical lines), water, waste (example, waste contamination in food-preparation areas), ventilation  (example, inadequate ventilation in the clinical laboratory), medical gas  (example, oxygen cylinders that are not secured when stored, or leaking oxygen lines, and other key systems that all pose hazards and when appropriate, they must be improved
3. designated individuals or authorities monitor regularly the quality of water received from a source, and the water used in chronic renal dialysis
4. collection of monitoring data for the utility system management program
   1. monitoring essential systems helps the hospital prevent problems
   2. monitoring data that are collected and documented are used to plan the hospital’s long-term needs on system improvements and in planning for upgrading or replacing utility systems

It is almost to the end of this rather long post.

I think it is also safe to justify from the foregoing discussion on utility system management that when a hospital – which is already JCI accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, satisfies the requirement for the Measurable Element 1 of MCI.20.1 which states that “The organization has a process to aggregate data in response to identified user needs”, if the hospital can provide evidence of documentation of a process to aggregate data i.e. in response to the identified user needs, when data is aggregated for utility system management.

This post ends what I wish to share all about the JCI Standard MCI.20.1, ME 1.

References:
Barbara JY 2011, Principles of risk management and patient safety, Jones & Bartlett Learning, Sudbury, MA, USA

Diane, LK 2007, Applying quality management in healthcare : a systems approach, 2nd edn, Health Administration Press, Chicago, Illinois, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn,  Jones and Bartlett Publishers, Sudbury, MA, USA