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Workshop #10:

IMPACT Registry

Data Quality

Reports

Presenter Disclosure Information

Joanne Chisholm RN, BSN, CEN

Joshua Kanter MD, FACC

Kristina McCoy MSN, CPHQ, NP-C

Joan Michaels RN, MSN, CPHQ

The following relationships exist related to this presentation:

No Disclosures

Objectives

1. Discuss relationship between Data Quality

Reports (DQR) & Outcomes Report (OR)

2. Demonstrate how to submit data

3. Discuss Data Quality Assessment reports

4. Discuss Completeness Assessment reports

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DQR Fail

• Correct data

DQR Fail

• Correct Data

DQR PASS

• Outcomes Report

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Submitting to the DQR

Vendor Data

NCDR DCT Data

DQR

Software Vendors

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NCDR Data Collection Tool (DCT)

Submit to DQR

Identify Patients with Errors

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Quality Check Errors & Warnings

Submit Data (from NCDR)

Submit with or without DPI

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Generating DQR

Encryption Key

• Site Specific

• Registry Specific

Submitting via Vendor Product

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All data sent to NCDR’s DQR

Vendor Data

NCDR DCT Data

DQR

Locating the DQR

More help?

Companion Guides

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Review Results

Data Assessment Report

Sort by Error Type

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Next Steps

1. Return to DCT & correct errors

2. Save data

3. Resubmit to DQR

4. Review DQR results to determine Pass/Fail

5. Progress to “Completeness Assessment”

DQR process

Review Results

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Yellow Status

Benchmark Inclusion Status

Failed Elements

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Supporting Thresholds

Next Steps

• Return to DCT & correct errors

• Save data

• Resubmit data to DQR

• View DQR results for pass/fail status

• Goal: PASS/PASS in both Data Assessment &

Completeness Assessment columns

Passing DQR

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Questions?

Quality Checks

&

System Alerts

Documentation:

• Submitting the quarterly data to the DQR

• I use the NCDR’s online DCT

• I am not able to submit 2012 Q4 data but I can

submit 2012 Q2.

Question 1) Why am I unable to submit

2012 Q4 ?

1. Not all patients are

entered

2. 2012 Q4 is not

over yet, so you

can not submit

3. One System Alert is

preventing the

submission

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Quality Checks & System Alerts

Documentation:

• Submitting the quarterly data to the DQR

• I use the NCDR’s online DCT

• I am not able to submit 2012 Q4 data but I can

submit 2012 Q2.

Question 1) Why am I unable to submit 2012 Q4 ?

1. Not all patients are entered

2. 2012 Q4 is not over yet, so you can not submit

3. One System Alert is preventing the submission

Warnings vs. Errors

Documentation

• Data deadline is approaching

• QC lists pages of Warnings and Errors

• Data listed as Warnings are accurate

Question 2) How do I correct the

Warnings?

1. Change data so they can be accepted by

the DQR.

2. Warnings do not require any changes.

3. Warnings will fail the DQR. Delete those

patients

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Warnings vs. Errors

Documentation:

• Data deadline is approaching

• QC lists pages of Warnings and Errors

• Data listed as Warnings are accurate

Question: How can I correct the warnings?

1. Change data so they can be accepted by the DQR.

2. Warnings do not require any changes.

3. Warnings will fail the DQR. Delete those patients.

Warnings - Outliers

Documentation:

• Attempting to submit to DQR

• Getting a Warning/Outlier indicating that the Length

of Stay is greater than 30 days

• Pt in house for one year, many pts remain inpatient

a long time

Question 3) How can I ever submit the data

with this warning?

1. Enter the discharge date with the date the

patient left the cath lab

2. Warnings are not the problem. There must be

an Error somewhere in the System Alert.

3. Delete the patient’s Episode of Care

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Warnings - Outliers

Documentation:

• Attempting to submit to DQR

• Warning/Outlier indicates LOS greater than 30 days

• Pt in house for one year

Question: How can I submit data with this warning?

1. Enter D/C date with date the patient left lab

2. Warnings do not cause the failure. There must be an

Error somewhere in the Quality Check.

3. Delete Episode of Care

Minimum Data Thresholds

Documentation:

• Quarterly submission is failing

• 22 patients in total

• Missing Cardiac Index on more than half

Question 4) How will we get our data passed the

DQR with missing C.I. values, we did not collect

them on all the patients?

1. Do not enter those patients that do not have

C.I. measured.

2. Review all the medical records. The minimum

threshold for C.I. is 10%. You only need to

have it entered 10% of the time.

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Documentation:

Quarterly submission is failing

22 patients in total

Missing Cardiac Index on more than half

Question: How will we get our data passed the DQR

with missing C.I. values, we did not collect them on all

the patients?

1. Do not enter those patients that do not have C.I. ex

measured.

2. Review all the medical records. The minimum

threshold is 10%.

Minimal Data Thresholds

Data Quality Report vs.

Outcomes Report

Documentation:

• Data deadline is February 28th

• Deadline is for 2012 Q4 data

• Any rolling 4 quarters can be submitted

Question 5) Is the Feb. 28 deadline for the Data

Quality Report (DQR) or the Outcomes Report

(OR) ?

1. Both.

2. The Data Quality Report only

3. The Outcomes Report only

4. There is no deadline for the DQR. You can

submit as many times as you want to the

DQR. A snapshot of the data in the DQR is

taken at the deadline for incorporation into

the Outcomes Report.

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Data Quality Report vs. Outcomes Report

Documentation:

• Data deadline is February 28th

• Deadline is for 2012 Q4 data

• Any rolling 4 quarters can be submitted

Question: Is the Feb. 28 deadline for the DQR or the

OR ? 1. Both.

2. The Data Quality Report only

3. The Outcomes Report only

4. There is no deadline for the DQR. You can submit as many

times as you want to the DQR. A snapshot of the data in

the DQR is taken at the deadline for incorporation into the

Outcomes Report

Data Deadlines DQR & OR

Documentation:

• Analyzing 2012 Q4 Outcomes Report

• 2012 Q3 column is blank

• 2012 Q3 was included in the 2012Q3 OR

• 2012 Q3 was then resubmitted recently to

make corrections

Question 6) Why is the 2012 Q3 column blank in

the current 2012 Q4 report?

1. 1. Each quarter is only reported upon once

2. Submission is “Red” in DQR at OR deadline

3. There were too few patients in the quarter to

allow the data to be included in the OR

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Data Deadlines DQR & OR

Documentation:

• Analyzing 2012 Q4 Outcomes Report

• 2012 Q3 column is blank

• 2012 Q3 was included in the 2012Q3 OR

• 2012 Q3 was then resubmitted recently to make

corrections

Question: Why is the column blank in the new report?

1. A quarter is only reported upon once

2. Submission is “Red” in the DQR at OR deadline

3. There were too few patients

Next Layer:

Data Collection

&

Definitions

Section A - DemographicsSEQ 2045 (Other ID)

Documentation:

• Hospital policy requires exclusion

of Direct Patient Identifiers (DPI)

• Using medical record number to code SEQ #

2045 (Other ID)

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Question 7) Will data entered in SEQ 2045 (Other ID)

be transmitted if we select “Exclude DPI” when we

submit data?

1) No

2) Yes

Section A - DemographicsSEQ 2045 (Other ID)

Documentation

• Hospital policy is submit without DPI

• Using medical record number to code SEQ # 2045

(Other ID)

Question: Will data entered in SEQ 2045 (Other

ID) be transmitted if we select “exclude DPI”

when we submit data?

1) No

2) Yes

Section B – Episode of CareSEQ 3090 (Date of Last Cardiac

Surgery)

Documentation:

• Pt admitted Jan. 5, 2013 (5th day of life)

• Underwent CV surgery Feb. 1, 2013

• Underwent urgent cath procedure Feb. 5, 2013

• Inpatient this entire time (since 1/5/13 admit)

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Question 8) How do we correct this error

code ?

Error Dates (code # 4015): Last Cardiac Surgery

Date (SEQ 3090) 02/01/2013 must be equal to or

prior to the episode of care Arrival Date (SEQ 3000)

01/05/2013

1) Leave the date field blank

2) Code No to Prior Cardiac Surgery

3) Change the date to be identical to the cath lab

Section B – Episode of CareSEQ 3090 (Date of Last Cardiac Surgery)

Documentation:

• Pt admitted Jan. 5, 2013 (5th day of life)

• CV surgery Feb. 1, 2013

• urgent cath procedure Feb. 5, 2013

How do we correct this error code: “Last CV Sx Date must be

equal to or prior to the episode Arrival Date”

1. Leave the date field blank

2. Code “No” to Prior Cardiac Surgery

3. Change the date to be identical to the cath lab

Section D - Procedure

Information SEQ 5035 (Operator’s NPI)

Documentation

• Attending completed ASD closure

• Fellow assisted attending

• Chief resident closed the femoral access site

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Question 9) No names appear in the drop

down. There is nothing to select. How is the

“Operator” field completed?

1) Leave the name field blank.

2) Enter the last name in the space that allows for

free text.

3) Leave this page, return to the NCDR

Maintenance page.

Section D - Procedure Information

SEQ 5035 (Operator’s NPI)

Documentation

• Attending completed ASD closure

• Fellow assisted attending

• Chief resident closed the femoral access site

Question: How is the “Operator” field complete?

1) Leave name field blank.

2) Enter last name in space that allows for text.

3) Leave page, return to NCDR Maintenance page.

THANK YOU