Chapter 24

1. Chapter 24 Utilization Management

2. Introduction • Utilization review and management programs have been required in United States hospitals participating in Medicare and Medicaid programs since 1965. • These assess the appropriateness of the delivery of health care to patients using evidence-based guidelines and predetermined criteria. • The overarching goal of a blood utilization management program is to better manage limited blood resources and eliminate waste while providing maximum benefit to the patient.

3. Approval and Support for Programs • Blood utilization programs may have multiple dedicated personnel for auditing, educational activities,and reporting and can require significant resources. • If properly executed, blood utilization management can produce significant indirect and direct cost savings. • Other key benefits, including enhanced safety and greater stewardship of a limited resource, can be achieved.

4. Lean Approach to Blood Utilization Management • Lean is a systematic approach to identifying actions within a process that create value, then optimizing the alignment of these actions to deliver to customers exactly what is desired, in the quantity desired, precisely when it is required. • An important goal is the elimination of waste.

5. Lean Approach to Blood Utilization Management (cont’d) • Acronym for identifying types of waste: DOWNTIME (Defects, Overproduction, Waiting, Non-value Added Processing, Transportation, Inventory Excess, Motion, Employee/People waste)

6. Peril • The Cruz-Gregurek model • Optimal value is the penultimate goal, and is accomplished by the development of standardized methods targeted to reduce both waste and peril. • In addition to financial and safety benefits, such interventions are expected to reduce variability in practice and provide better stewardship through optimization of a limited resource.

7. Value Stream Assessment • Application of the Lean paradigm begins with iteration of the value stream and assessment of the current state. • The value stream mapping team identifies all sub-processes necessary to bring the finished product to the patient. • Balance improvements in one area with potential to increase waste over the total system.

8. Value Stream Assessment (cont’d) • The traditional, or “current state,” map of the value stream reveals two disjointed processes. • Paradigm shift: greater risk reduction can be achieved by considering both individual component safety measures and utilization optimization strategies.

9. Basic Elements of Utilization Management • Metrics must be chosen to allow an assessment of the current state and scope of the problem. • Evidence-basedtransfusion guidelines must then be written and deployed. • Review criteria must be established to monitor physician compliance with guidelines.

10. Blood Utilization Review • Attempts to optimize transfusion utilization by minimizing inappropriate transfusion • Comprised of three broad categories of audits • Retrospective • Concurrent • Prospective

11. Retrospective Blood Utilization Review • Can be performed after the transfusion event has taken place and can occur when convenient without interrupting other staff duties • Detailed chart reviews by nursing or physician staff to determine appropriateness • Transfusion events occur in the past and the inappropriate transfusion is not prevented, merely identified later

12. Concurrent Review • A type of retrospective review that occurs shortly after the transfusion while case details are still fresh in the mind of the ordering practitioner • Allows review of the relevant guidelines with the ordering physician to encourage future compliance

13. Prospective Review • The most complex method and requires the interaction of blood bank personnel and the physician evaluator • This type of audit methodology uses manual or semi-automated methods and requires real-time evaluation of component requests. • The clinician’s order is reviewed in real time in light of available patient lab data and clinical information.

14. Prospective Review: Possible Outcomes • Approval of the order after additional information is provided • Consultation and agreement upon a more appropriate component • More informed decision resulting in cancellation of the transfusion order

15. Targeted Prospective Review • When this concept is applied to the blood bank, targeted prospective review involves ongoing prospective monitoring of one or a few specifically selected products or indications for utilization of transfusion services.

16. Discontinuous Prospective Review • This type of review is combined with retrospective or concurrent review strategies, and selectively triggered when significant deviations are identified. • It may be limited to a particular product type, DRG, clinical service, or individual ordering clinician.

17. Intervention Strategies • Each particular hospital and situation may require different interventions or perhaps a combination of strategies to mitigate inappropriate practices. • Interventions may be categorized as educational, punitive, or confrontational. • They may be employed individually or collectively, depending on the culture of the institution.

18. Educational Strategies • May require a hospital-wide focus if inappropriate utilization occurs in multiple departments or in no easily categorized groupings • Lectures, grand rounds, and job aids

19. Punitive Strategies • Involve reporting aberrant ordering practices to certain peer groups or hospital administrative groups relevant to the ordering physician • These groups must agree with the mission of the blood utilization program and endorse the metrics and guidelines or such reports will be ignored.

20. Confrontational Method • Involve preventing or obstructing certain physician orders • With institutional approval, system-wide constraints can be placed on transfusion orders. • Gatekeeping is another confrontational method that requires approval of any transfusion order not meeting predefined criteria.

21. Behavioral Influences • There are three types of behavioral influences that can impact program success and should be considered in the planning process • Direct influences • Local influences • External influences • All three of these must be addressed to ensure quality and uniformity of care while avoiding unnecessary conflict and confusion.

22. Blood Order Sets • In Lean manufacturing, visual control is important as a means of standardization. • A utilization management equivalent is the use of blood order sets. • They are a standardized method to clarify indications and enforce guidelines during physician order entry. • This process may be paper or electronic, and should be simple and intuitive to use.

23. Education • Numerous studies suggest that educational efforts alone may impart a substantial improvement to blood utilization. • A small group discussion with a physician group about current guidelines for plasma transfusion • Formal lectures at grand rounds • Resident education

24. Policy Deployment • Just as a utilization management program needs careful assessment and thoughtful development of policies and guidelines, initiating such a program requires planning. • Hoshin kanri is a strategy of examining all of the desired goals and ordering projects based on balancing priority with ease of accomplishment to ensure progress. • Change is thereby enacted in smaller pieces, rather than broad instantaneous reform.

25. Personnel • Once the scope and nature of the blood management program is agreed upon, attention focuses on allocation of resources and identification of personnel for planning, approval, and implementation. • The planning team must develop specific policies, guidelines,and procedures that fall within the constraints and expectations of the entire hospital system.

26. Transfusion Safety Officer (TSO) • A unique career role that developed in Canada and European blood banks • TSOs are commonly medical laboratory scientists or BSN nurses. • They coordinate and participate in most functions within the blood utilization program including, but not limited to, audits of transfusion records, quality assurance,and educational functions.

27. Information Technology • For most Utilization Management programs, the inclusion of a team member from Information Technology will be important. • Data mining and analysis will be critical in assessing the current state and designing reports for continuous monitoring. • A great deal of information can be gleaned and processed by well-constructed queries to the LIS, electronic medical record, billing system, and other databases.

28. Design Considerations • Interactions between blood utilization review and intervention strategies and the potential impact on the ordering clinician

29. Continuous Improvement • Also known as Kaizen, through Lean or another quality process, is required for long-term success of a blood utilization management program • Improvement teams should be deployed at all organizational levels. • Blood bank technologists, nursing staff, and ordering practitioners should be included.

30. Continuous Improvement (cont’d) • The long-term success of the program should be considered a safety and cost-saving investment dependent on the adequate allocation of resources. • The Transfusion Committee is an ideal forum for the review and assessment of the success of the program. • Because of its multidisciplinary nature, feedback can be shared between the blood bank and clinicians.