The Exec: How to Succeed in Utilization Management
By Christopher Cheney
The new CMO of Morton Hospital, which is part of Brown University Health, brings a wealth of experience to the role, including previously serving as the health system’s senior medical director of utilization management.
Jill O’Brien, MD, became CMO and medical director of hospital medicine at the hospital on Oct. 1. Prior to taking on the new dual role, O’Brien served as vice president of strategy at Brown University Health.
The essence of utilization management is providing the right care for the right patient in the right setting at the right time, according to O’Brien.
“We do a lot of work in creating pathways for the right treatment options for patients,” O’Brien says. “We want to make it easier for clinicians and care teams to choose the right options.”
Setting up these pathways involves both physicians and nurses.
“You need a strong utilization management nursing program that understands the standards of care,” O’Brien says. “You need physician advisors who understand the standards of care and the best practices as well as how difficult it can be to work in the hospital setting.”
An example of creating pathways that support utilization management is when a patient comes into an emergency department complaining of back pain.
“We want to have a simple and easy way to treat acute pain, then get adequate follow-up such as with a pain specialist or physical therapy,” O’Brien says. “One of the goals is to avoid unnecessary hospitalization or unnecessary imaging in the emergency department.”
Utilization management includes determining whether services provided in the hospital setting should be provided in the outpatient setting instead, according to O’Brien.
“Then you should find ways to put in electronic referrals, follow-up care, wrap around services, and post-ER phone calls to check on patients,” O’Brien says. “These measures allow the care team in the hospital to feel more confident that the patient will receive the services they need in the outpatient setting without having to come to the hospital to receive care.”
Serving in two roles
There is significant synergy in serving in the dual role of CMO and director of hospital medicine, O’Brien explains.
“Hospitalists are crucial in the efficiency and throughput of the hospital as well as quality and safety,” O’Brien says.
In the short time O’Brien has served in the dual role at Morton Hospital, she says she has identified opportunities for improvement, such as streamlining patient admission timelines.
“When a patient is identified as needing admission, we should be able to get that patient to a bed quicker and provide care on a more timely basis,” O’Brien says.
“For example, we have an opportunity to streamline which patients get telemetry, and nurses can be empowered to remove telemetry when it is no longer necessary based on best-practice parameters,” O’Brien says.
Reducing length of stay
O’Brien helped lead an effort to reduce length of stay by 12 hours at Brown University Health’s flagship hospital, Rhode Island Hospital in Providence.
“Patient throughput is the lifeblood of a hospital,” O’Brien says. “There are many people who are involved in patient throughput, and there is no silver bullet for reducing length of stay. It takes a coordinated effort. You need to identify patient throughput challenges or where there are bottlenecks, then work through those barriers.”
Imaging is a common area where bottlenecks can arise.
“For example, there can be a bottleneck with MRI exams, and you need to determine whether an MRI exam needs to be done in the inpatient setting or can be done in the outpatient setting,” O’Brien says.
Successful efforts to reduce length of stay often require changing behavior of care teams.
“Historically, physicians have been resistant to change, particularly if they have been in practice for many years,” O’Brien says. “If you can demonstrate with early adopters how you can improve patient throughput, a length of stay initiative can gain momentum.”
“First, we looked at what was happening in the echocardiogram departments,” O’Brien says. “We found that the echocardiogram offices were efficient, but there were too many echocardiograms being ordered. We had a cardiologist and neurologist educate the hospitalists on the indications for inpatient echocardiograms, and we were able to match the capacity for echocardiograms in our hospitals with the volume of the orders.”
Christopher Cheney is the CMO editor at HealthLeaders.