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 1
DQR Fail Correct data DQR Fail Correct Data DQR PASS Outcomes Report 2
Submitting to the DQR Vendor Data DQR NCDR DCT Data Software Vendors 3
NCDR Data Collection Tool (DCT) Submit to DQR Identify Patients with Errors 4
Quality Check Errors & Warnings Submit Data (from NCDR) Submit with or without DPI 5
Generating DQR Site Specific Registry Specific Encryption Key Submitting via Vendor Product 6
All data sent to NCDR s DQR Vendor Data DQR NCDR DCT Data Locating the DQR More help? Companion Guides 7
Review Results Data Assessment Report Sort by Error Type 8
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 9
Yellow Status Benchmark Inclusion Status Failed Elements 10
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 11
Questions? Quality Checks & System Alerts 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 12
Quality Checks & System Alerts 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 13
Warnings vs. Errors 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 Attempting to submit to DQR Getting a Warning/Outlier indicating that the Length of Stay is greater than 30 days Ptin house for one year, many ptsremain 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 cathlab 2. Warnings are not the problem. There must be an Error somewhere in the System Alert. 3. Delete the patient s Episode of Care 14
Warnings - Outliers Attempting to submit to DQR Warning/Outlier indicates LOS greater than 30 days Ptin 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 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. 15
Minimal Data Thresholds 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%. Data Quality Report vs. Outcomes Report Data deadline is February 28 th 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. 16
Data Quality Report vs. Outcomes Report 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 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 17
Data Deadlines DQR & OR 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 - Demographics SEQ 2045 (Other ID) Hospital policy requires exclusion of Direct Patient Identifiers (DPI) Using medical record number to code SEQ # 2045 (Other ID) 18
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 - Demographics SEQ 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 Care SEQ 3090 (Date of Last Cardiac Surgery) Ptadmitted Jan. 5, 2013 (5 th day of life) Underwent CV surgery Feb. 1, 2013 Underwent urgent cathprocedure Feb. 5, 2013 Inpatient this entire time (since 1/5/13 admit) 19
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 cathlab Section B Episode of Care SEQ 3090 (Date of Last Cardiac Surgery) Ptadmitted Jan. 5, 2013 (5 th day of life) CV surgery Feb. 1, 2013 urgent cathprocedure Feb. 5, 2013 How do we correct this error code: Last CV SxDate 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 cathlab Section D - Procedure Information SEQ 5035 (Operator s NPI) Documentation Attending completed ASD closure Fellow assisted attending Chief resident closed the femoral access site 20
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 21