Did you know that, almost hidden away in the Conditions of Participation, there is an oft-overlooked requirement that is ideal for increasing medical staff involvement and improving practice evaluation?

The reason this requirement is so often missed is that, unlike all other Conditions of Participation, no accrediting body—Joint Commission, DNV, Inc., the Healthcare Facilities Accreditation Program or the Center for Improvement in Healthcare Quality—are allowed to survey for it as part of deemed status. The requirement, which states that hospitals must have a “utilization management committee,” can only be surveyed by CMS.

But it turns out this committee can be an incredibly useful tool for the medical staff, according to Cary Gutbezahl, MD, of Compass Clinical Consulting.

“Most hospitals aren’t ever surveyed to see if they have a functioning utilization management committee or UMC,” says Gutbezahl. “The reality is very few ever get surveyed to look at this condition.  And most don’t have an active program—if they do, they go through the motions and don’t get a lot of benefit out of it.”

But looking at the UMC as a paper exercise is a mistake, says Gutbezahl.

“A well-designed one gets a lot of attention from physicians,” he says. “A UMC can help change the way you utilize resources.”

The UMC provides an outlet to examine important utilization issues, such as length of stay, readmissions, and even use of testing like MRIs CAT scans, and other routinely ordered tests.

So how can your organization make use of this oft-overlooked CoP?

Physician involvement, and physician ownership.

“The key to making it an effective committee in my opinion is making it a peer review medical staff committee. It reports to the medical executive committee, so it is predominantly medical staff members,” says Gutbezahl. “Usually the only non-med staff person when I help set these committees up is the director of case management as they provide a lot of the information necessary to review cases.”

And obviously you will want to invite as ad hoc members anyone whose department is identified as a recurring concern by the reviews, such as radiology or physical therapy. 


What can an effective UMC do that other UMCs do not? It’s all about focus, says Gutbezahl.

“A lot of committees focus on high-level data analysis—what is our length of stay, etc.,” says Gutbezahl. “But a UMC is truly effective when you use it as a peer review committee. Look at specific cases and really discuss those cases. Assess utilization practices of the physician, and also within particular departments or specialty groups.”

Ask: what can we learn from this and what do we not want to do again?

“If you use it as a peer review committee, the physicians are much more likely to want to come to the meeting,” he says.

In addition, this peer review concept allows for an increased communication with members of the medical staff.

“Frequently the UMC will send a letter to the physician stating they had reviewed their case, thought the length of stay was excessive, and felt on specific days the patient was not getting hospital level services,” says Gutbezahl “Medical staff members on the committee really take the bull by the horns, assessing each other’s practices.”

As a committee, the UMC reports to the MEC, and might make recommendations to the MEC but their findings become incorporated into their ongoing provider performance evaluation.

“Even though Ongoing Professional Practice Evaluation is Joint Commission only, all hospitals have to have something for ongoing review,” says Gutbezahl.

Interestingly, the UMC is one of those components that physicians are not asking on their own, but if they are introduced to it in the right tone, Gutbezahl notes, they see the value in it and become very much engaged.

“They’re using their professional judgment as peers and their efforts are having an impact on the way care is provided at the hospital,” says Gutbezahl.

The key phrase however: in the right tone.

“The problem with UMCs that are not working is that so much time is spent on high level discussion,” says Gutbezahl. “An organization will note that their length of stay is up, but there isn’t an answer to the question of what do we do now? But if you get your medical staff into a territory they are comfortable with, individual cases, observing the medical record, they know they are doing something constructive.”

For most organizations, there is a missed opportunity to actively involve the UMC. They know, for example, that their length of stay is up, but they are not using this type of resource to craft solutions.

“Sometimes improving case management can help, but case management is great at identifying the problems but doesn’t address the issue or professional practice,” says Gutbezahl. “To improve physician practice you need a peer review committee. This is what their review is really all about—complications are being reviewed by a group of the physician’s peers.”


For a UMC to get rolling in an organization without one, the best place to start is with a physician champion.

“This could be your chief medical officer, it could be a physician advisor for utilization management, it could be a hospitalist or the chief hospitalist,” says Gutbezahl. “It could be any number of different people, but that person has to work in concert with the head of the case management program.”

The person who is acting as champion should know about the problems that are coming up day to day among physicians, and should work with case management to find the cases that warrant review.

“Ultimately the goal of the UMC is to reduce the use of services that cost money that really aren’t necessary to the care of the patient,” says Gutbezahl.

From the med staff standpoint, physicians are increasingly aware of the changing world of healthcare, not just the aggregate costs but specifically in inpatient costs.

“Medical staff physicians involved in patient care are going to be stepping up to the plate for these kinds of initiatives,” says Gutbezahl. “What we’re fundamentally talking about is eliminating waste. We’re talking about the extra days where better care and planning would have resulted in shorter hospitalization.”

Not to mention, Gutbezahl notes, the fact that hospitals aren’t the safety place for a patient to be.

“In another life, I worked in bone marrow transplants,” says Gutbezahl. “We wanted to get the patients quickly out of the hospital. Hospital acquired organisms are much harder to treat than community based organisms.”

Patients don’t benefit from waiting from Friday to Monday for a stress test, for example. The fact is that if they need to be hospitalized while they wait, the patient may in fact be better served if the organization can find a way to conduct that stress test sooner. 


When looking at your UMC to judge its impact, the proof is in the pudding, Gutbezahl says.

“If the UMC is bending practice patterns, they’re probably doing okay,” he says. “Obviously if you’re not getting a significant benefit you should ask yourself what is not working? Look for outside help, someone to come in and assess what you’re doing and give you ideas for better practices.”

It might sound counterintuitive, but the UMC should avoid the big picture.

“It’s nice to think we’re migrating toward a population health mentality but the reality is that physicians focus on the patients on an individual basis,” says Gutbezahl. “They’re more comfortable dealing with individual assessments rather than looking at statistical numbers which then raise more questions than answers.”

High level data raises multiple questions whereas individual cases give you the kinds of details you need to know to talk to the attending physician, he says.

“Case by case reviews provide much more information to reach a conclusion you can then act upon, where high level data doesn’t provide much data for immediate problem solving,” says Gutbezahl.

Organizations will also want to loop in the appropriate metrics when creating or improving a UMC. At the grossest level, you are looking at length of stay, numbers of unnecessary hospital days, but when you get to the granular level, Gutbezahl says, you’re going to be looking at changes in individual physician performance, changes in specific resource utilization, and changes in cost for specific diagnosis-related groups (DRGs) or DRG clusters.

It is worth asking: will CMS ever cross the hospital’s front door and examine your UMC process?

“I can’t say no one will ever come in and look at it,” says Gutbezahl. “I always believe as long as the rules are on the books, CMS might come in and audit a hospital and look at what they’re doing. I think there’s some vulnerability if they don’t have an effective UMC that they might get dinged with something. It won’t give them an immediate jeopardy finding but it will give them a condition level finding. This could increase as CMS conducts validation surveys, so you’ll want to put something on paper—it’s pretty straightforward for what CMS requires.”

And for the most part, the benefit of a UMC is not to prepare for CMS, but rather to benefit from the focus a UMC can provide with physician involvement and peer review.

“What CMS requires provides are some prescriptive details on the minimum things you need to do but doesn’t provide a blueprint,” says Gutbezahl.

Why haven’t hospitals been more proactive in creating and involving UMCs?

“CMS hasn’t been badgering them about it. It used to be more important to CMS when they paid more for outlier days and outlier costs, but they’ve kind of let the utilization management condition become less of a focus,” says Gutbezahl.

“I’ve seen cases where a physician has cut 1.8 days off his average length of stay based on feedback from the UMC,” says Gutbezahl. “He was then invited to be a part of the process and his performance improved tremendously. The emphasis of this committee is that there is a huge opportunity for hospitals to reduce costs.”


The bottom line is that the real benefit is to the hospital, not to CMS.

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