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Continuous quality improvement and the utilization management process.

T Schwarz1

  • 1Community Health Plan, Pleasant Valley, NY 12569.

Medical Interface
|July 7, 1994
PubMed
Summary
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A health maintenance organization (HMO) is implementing a formalized utilization management program. This initiative simplifies complex processes using quality improvement principles inspired by Deming

Area of Science:

  • Health Services Research
  • Quality Improvement Science
  • Managed Care Management

Background:

  • Formalized utilization management programs are essential for health plans.
  • Integrating quality improvement processes can optimize these programs.
  • Managed care organizations face challenges in simplifying complex projects.

Purpose of the Study:

  • To describe the process of developing a formalized utilization management program.
  • To illustrate the application of quality improvement principles in a managed care setting.
  • To share practical experiences of a health maintenance organization (HMO).

Main Methods:

  • Case study approach detailing an HMO's experience.
  • Application of Deming's quality improvement teachings.

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  • Focus on simplifying a complex project.

    • Main Results:

    • The HMO is actively developing its utilization management program.
    • Deming's principles are being used to manage project complexity.
    • The organization is documenting its journey and lessons learned.

    Conclusions:

    • Formalizing utilization management with quality improvement is feasible.
    • Simplifying complex projects requires structured approaches like Deming's.
    • Sharing organizational experiences can benefit the managed care industry.