C O L L A B O R A T I V E C A S E M A N A G E M E N T
A Medical Director’s Perspective
Tools for a Medical Director
By William Wessinger, MD
As case management continues to mature into an integral component of quality care in almost every hospital, an increasing number of
departments utilize a full-time physician advisor or medical director. The recent ACMA survey reports that in over 60% of those departments, the
medical director has a defined job description with specific expectations and accountabilities. This represents a positive shift for the profession
because it reflects an understanding of the scope and depth of physician support necessary to a successful, integrated case management service.
An effective job description will be the tool to provide the
institution’s definition of success in the position. It will define:
• the purpose of the position
• the reporting relationships
• the responsibilities of the position
• the availability the physician must maintain
• the span of control, if there is any
• the compensation model to be used, including any incentives
• the links between goals and compensation
While some components of the job description are a
recitation of the department structure and some goals link with
the department goals, it is very important that the purpose be
strategic in nature. The purpose of the position drives not only
what the physician makes his or her priority on a daily basis but
also defines the strategic position of the department in the care
delivery model. A job description that sets expectation for a
proactive medical director will position the case management
department to lead clinical and cost effectiveness efforts.
For instance, the job description that defines my own work
as a medical director clearly sets out the purpose as:
“Provides Medical Staff leadership and support to team
members of Clinical Resource Management (case
management function). Provides direction in challenging
physician practices to achieve the desired goals of Clinical
Resource Management, intervening as indicated
indicated.”
The defined reporting relationship insures that both real and
perceived authority is clear. The responsibilities and goals
outlined specifically support the position’s purpose. With a
clearly defined job description in place, the remaining tools
necessary for success vary somewhat by hospital. However, there
are basic types of tools required.
THE TOOL BOX
To manage key clinical and quality indicators such as ALOS,
utilization review denials, and cost implications of outliers, case
management services and medical directors must have access to:
• specified admission criteria (e.g. InterQual, Milliman or other),
• case management software,
• knowledge of payer contract requirements,
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• an easily accessible (online) peer network such as
ACMA’s Learning Link.
• risk-adjusted clinical and utilization databases,
• UR and performance improvement plans, the institution’s
policies and procedures and an effective UR committee,
• clinical decision support system,
• evidence-based medicine guidelines,
• Medical Staff Bylaws
• well-developed standing orders, clinical pathways and,
ideally, computerized physician order entry (CPOE).
Perhaps one of the most important “tools,” is actually the
environment in which the case managers and medical director work.
A culture that embraces continuous process improvement and
quality improvement techniques will provide the context for success.
Though not a “mandatory tool,” a hospitalist program will also
contribute to more marked case management success. Hospitalist
programs can provide increased consistency implementing
clinical pathways and provide the opportunity for relationship
development between hospitalists and case managers who work
together frequently. A hospitalist program also narrows the
number of physicians the medical director works to influence.
Hospitalists adopt clinical pathways and become experts in the
hospital-based care delivery for specific groups of patients. Over
time, data will demonstrate the clinical effectiveness and quality
improvements that result, providing the opportunity to be a
catalyst for change throughout the medical staff. Medical staff
members slow to change or adopt new care guidelines usually
reconsider when presented with influential data.
USING THE TOOLS
All the software, decision-support systems and clinical
guidelines are only useful when they transform the vast available
data into useable information. To monitor processes, track
progress towards goals and identify outliers, a successful medical
director will rely on a variety of critical reports. These reports,
varied in frequency and customized to the institution’s goals and
unique processes, will include:
1. weekly outlier reports
2. weekly denial of payment reports
3. avoidable days reports
 w w w . a c m a w e b . o r g

4. inpatients on outpatient observation unit
5. weekly time of discharge report
6. performance indicators from the finance department
7. product line profitability reports
8. denial of payment appeal register
The proper use of these reports is not punitive. The
appropriate use is to identify areas of necessary education or
support for the case managers, identify progress towards goals
or provide insight to process improvement efforts. Some
examples are below:
EXAMPLE A: WEEKLY DENIAL OF PAYMENT REPORT
GEORGIA MEDICAID
ACCT # PT. NAME DOB ADMIT TOTAL CHGS
____ _______ ___ 09/16/05 $7,373.34
Note the comment field in Example A that not only
identifies the actions to recoup payment but also the
educational need to discuss the Medicaid rule that was the
underlying cause of the payment denial with staff members.
Addressing specific cases in real-time is a much stronger
and time-efficient training tool than periodic in-servicing
unless a trend or pattern in broader staff misunderstanding
becomes apparent.
One goal of the medical director is to increase the number
of discharges that occur by 11:00 a.m. The report shown as
Example B not only provides a tracking mechanism to
understand progress towards the goal, it also provides a
mechanism to spot units that may have discharge processes
from which other units may learn. REH is notably closer to the
target goal than others are. Likewise, several of the units had
later discharge times this week than YTD – were there
circumstances that were unique or is there a consistent slipping
away from the goal? This provides the mechanism to identify
the areas that might need more intensive performance
improvement work.
SUCCESS IS INTERDEPENDENT
Ultimately, the success of any case management service is a
result of the synergy between the case managers, medical
ACCT BAL COMMENTS director, the tools at their disposal and their competence and
$7,373.34 Fetal demise. proficiency at using the available tools. To insure the best
Was admitted,
Medicaid
contribution from a medical director, a comprehensive job
requires description is necessary. As well, providing the infrastructure
Observation
status. Need
and environment are critical. A culture of quality and process
to stress rule improvement and a wide variety of software and data tools will
to staff.
Rebill as Obs? put information in the hands of case management staff
members. Then, leadership and staff members must use
creativity and expertise to turn the information into improved
quality and efficiency of patient care.
William Wessinger, MD is Medical Director of Clinical Resource
Management and Case Management at Memorial Health
University Medical Center in Savannah, GA. His M.D. is from
The Medical University of South Carolina. He is board-certified
by the American Board of Orthopedic Surgery with added
qualifications in Hand Surgery.

EXAMPLE B: WEEKLY DISCHARGE TIME REPORT

MEMORIAL HEALTH UNIVERSITY MEDICAL CENTER INPATIENT DISCHARGES AVERAGE DISCHARGE TIME BY STATION / AS OF WEEK ENDING 04/15/2006

■ YTD 04 /15 / 2006 ■ CURRENT WEEK 04 /15 / 2006

6:00 PM

4:00 PM

2:00 PM

12:00 PM
AVERAGE TIME

10:00 AM

8:00 AM

6:00 AM

4:00 AM

2:00 AM

12:00 AM
Station 4AB Station 4CN Station 5CS Station 5NS Station 5VA Station REH Station CSU Station GIS Station ORT Grand Total

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