Healthcare Quarterly

Healthcare Quarterly 5(4) June 2002 : 8-8.doi:10.12927/hcq..16506
Departments

Letters: Utilization Management: Adding Value through Front-Line Nursing Participation

Patty Welychka and Jo Anne Shannon

Abstract

We were intrigued to see the focus on nursing best practice guidelines in the most recent Hospital Quarterly (Vol. 5, No. 3), and would like to share a bit about how bedside nurses are being included in decision and policy-making in our organization. The Niagara Health System is currently in the process of defining quality of care and determining how to improve organizational performance. Given the importance of this issue, and its concomitant impact on accountability and responsibility, it makes sense that nursing professionals be invited to participate in utilization management committees so that they have input on key decisions related to the best interests of patients. As we move forward to link the appropriate professionals to these committees, we see that a client-centered approach does impact organizational performance and quality patient care. If the processes are clearly defined by those with responsibility for care, the efficiencies can, and will, be realized.

It's time for front-line nurses to begin to take action on how their bedside processes affect the dollars allocated to hospitals. In our experience, having bedside nurses involved on key decision-making committees has added value to the discussions at the table. It has also increased the awareness and commitment of the nursing profession to participation in the development of recommendations and in the implementation of any decisions made.

One prime example is in the area of utilization data which are often open to interpretation. Since these data are derived from nursing and physician activities, it is important for nurses to understand that clinical processes can influence data evaluation down the road when overall hospital performance is measured.

Clinical activities that impact on utilization management data could include:

  • Expedient triage and documentation through the Emergency Department.
  • Identifying patient populations that require Quick Response Services to avoid inappropriate admissions.
  • Admission protocols to reduce time spent in Emergency, specifically those needing urgent transfer to ICU.
  • Turn-around time of beds ready for patients on an acute-care floor.
  • Clinical Pathways to ensure coordination of care and appropriate resource use.
  • Accurate documentation of Nursing Workload Measurement activities.
  • Working with the Case Manager and the clinical team on discharge plans.
  • Patient and family education.
  • Documentation on a day-to-day basis about conditions that may affect the overall Resource Intensity Weight of a patient visit (i.e. ulcer staging).
  • Identifying patients who need alternate levels of care - moving from ICU to step-down and then to medicine in a timely fashion, or those who are medically stable and are waiting for placement in a nursing home or long-term care facility.
  • Plan for tomorrow - today! Thinking past the tasks of the current shift.
  • Ensure test results are made available in a timely fashion to physicians.
  • Discharge the patient when ready - even if after hours or on weekends, if safe to do so.

In Ontario, front-line nursing activities such as these can directly affect utilization management and benchmarking numbers in databases maintained by: Health Services Restructuring Analysis; Canadian Institute for Health Information; Ministry of Health and Long-Term Care Planning and Decision Support Tools; and Comparison Hospital Activity Programs, to name a few. But, what are the incentives to participate in ensuring these activities that affect utilization are carried out in a timely fashion - especially when nurses know that as soon as they discharge a patient, another admission is waiting? Will they be able to call in more nursing staff to adjust to the higher acuity? Finding the right balance between reduction in length-of-stay and increased nursing acuity is a delicate and sensitive one. Often these two initiatives are not simultaneously evaluated. Therefore acuity of patient care often rises before staff increases are implemented, if at all. The frustration for nurses is that they see little, if any, incentive to send patients home after-hours or on weekends. Nurses are committed at this point because they know that when delays are reduced and care is streamlined, it actually improves outcomes for patients. Thus, the involvement of front-line nursing at the table when sensitive discussions are taking place such as changes in staffing levels, reallocation of beds or bed reductions and changes in policies and procedures cannot be minimized.

About the Author(s)

Patty Welychka, RN, CHE, CPHQ
Regional Director Utilization, Niagara Health System

Jo Anne Shannon, RN
President of ONA in Niagara Region

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