Q&A: Determining UR reporting structure

Q: Our utilization review (UR) committee originally took a more strictly peer review role but over time its scope and responsibilities have broadened. We're not sure that it still makes sense for the UR committee to be categorized as a subcommittee of the medical staff. What is the current recommended reporting structure for a UR committee?

A: UR committees have historically been subcommittees of the medical staff, but that seems to be gradually changing, as UR is no longer considered a peer-review activity but rather one with broader scope and responsibility. The CoPs allow the UR committee to be categorized as one of the following:

• A staff committee of the institution
• A committee established by the local medical society and some or all of the hospitals in the locality
• A committee established in a manner approved by CMS

These last two options work best in small hospitals, such as critical access hospitals, where it may be difficult to find two physicians willing to contribute their time to fulfill the UR responsibilities. Under the provision that the UR committee may be an institutional staff committee, hospitals are aligning UR committees with the fiduciary responsibilities of the board of directors as well as the medical staff. Alternatively, the UR committee may be structured as a joint committee of the board and the medical staff. A best practice hasn’t materialized yet, as hospitals are still experimenting with alternative alignments. Nevertheless, as the board’s governance accountability increases beyond financial responsibilities—and to detract from any cynics who might otherwise perceive UR or utilization management as only financially driven—it’s probably best to position the UR committee under the board’s performance improvement committee. Doing so may help ensure that hospital leadership is taking clear, appropriate measures to provide the safest healthcare in the most efficient and effective manner. Whatever reporting structure is chosen, the intent is to bring utilization issues to the timely attention of the board without going through the multiple layers of bureaucratic review typical of many medical staff bylaws.

For more information see The Hospital Guide to Contemporary Utilization Review, Second Edition.