Introduction to Quality Assurance
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INTRODUCTION
The Utilization Management Program of the Naval Hospital Guam facility is one which is designed to ensure that high quality, cost efficient health care is delivered to all members of the community. The Utilization Management Division is responsible for implementing a Utilization Management Plan which will monitor the appropriate usage of the health care facilities, services and its resources. These services may include utilization reviews, case management, discharge planning and outcome-based evaluations. The Utilization Management Program is completely planned and put into action by this division. It is also responsible for coordinating and monitoring access to care, developing programs, and evaluating the quality of healthcare services in accordance with guidelines from the Department of Defense, Lead Agent, Regional 12, and Health Affairs.
UTILIZATION MANAGEMENT PROGRAM
The following provides an overview of the various functions of the Utilization Management Program at the Naval Hospital Guam facility. The program requirements may vary based on the member.
Specialist Referrals— The Primary Care Physician (PCP) may request a consultation from a participating specialist physician at any time. The PCP determines the number of visits authorized. Specialists may include — Gynecologist, Radiation Oncologists, Ophthalmologists, Pediatric Ophthalmologists, Retinologists and Allergists etc.
Emergency Room Services —An emergency medical condition is defined as a condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:
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Placing the health of an individual or, with respect to a pregnant woman, the woman’s health and that of her unborn child in serious jeopardy
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Serious impairment to bodily functions
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Serious dysfunction of any bodily organ or part
Out-of-Plan Referrals— All out-of-Plan referrals require Plan prior authorization at Guam. These requests are reviewed on an individual basis. Determinations are made based on the patients medical needs and the availability of services to meet these needs within the provider.
Tertiary Care Services— All referrals to plan tertiary care centers are reviewed on an individual basis. The members medical needs and the availability of requested services within the non-tertiary care network are taken into consideration.
Discharge Planning — Patients who require continuing care after release from the hospital are identified and the appropriate services are arranged through participating home care, medical equipment and other providers.
COMPARISON AND REVIEW
The facility’s Utilization Management Program may need continued review on a periodic basis in order to keep it on par with the model Utilization Management Program as described by the HealthCare Advisory Council. In keeping with these lines, the program is updated, reviewed and approved annually by a team from the HealthCare Advisory Council itself. The different types of reviews and how they lead to improvements in the quality of care is now outlined below:
Prospective Review — Using InterQuals’ Level of Care Criteria all elective inpatient hospitalizations are reviewed to assure that services are provided in the appropriate setting. This ensures that the health care services