Advantages of Exception-based Quality Review

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By Carolyn J. Humphrey, R.N., M.S., F.A.A.N. 
CJ Humphrey Associates

Exception Based Quality Review Home HealthTo address the healthcare environment’s Triple Aim of improving quality, assuring continuing care management and improving cost effectiveness, organizations increasingly must be vigilant about performing quality reviews. Clinical documentation that is accurate, consistent, timely and meets regulatory and billing requirements has never been more important – or more costly.

Agencies have created quality review departments staffed by clinicians dedicated to the time-consuming process of reviewing every patient’s complete record. That review includes identifying inconsistencies, reporting back to the clinician, and monitoring and overseeing until all issues are resolved. As Karen Utterback described in posts dated May 7 and May 9, recent studies have indicated that “Quality staff have devised some amazing ‘home-grown’ work processes and lots of manual checking and workflow processes that can create room for inadvertent errors, omissions and schedule oversights.”

Exception-based review in an electronic medical record filters individual patient information entered by the clinician and highlights only the exclusions from the prescribed limits, such as evidence-based assessments, interventions and outcomes measures. The filtering functionality helps assure the system catches the “easy stuff” to support a higher level review. It’s like the game in which you compare two pictures and identify the differences. The best news is – the EMR does it for you!

If the EMR also provides real-time alerts to clinicians when there is an exclusion from the limits and allows them to address the issue immediately, the exception-based review can be even more reliable and less time-consuming.

So, in addition to the clinical benefits provided by an EMR that incorporates evidence-based practice and clinical decision support, exception-based review can help support several organizational and managerial efficiencies, including:

  • Improving identification of higher level exceptions
  • Eliminating hours of tedious manual review without compromising data quality
  • Increasing productivity and time management
  • Reallocating personnel for other organizational benefits
  • Providing specific feedback for agency educational programs

Next: Strategies and examples of how you can adopt exception-based review in your organization.

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