Quality Improvement for Institutions

Data Quality

The NCDR Data Quality Programs (DQP) include a series of checks and balances to validate and ensure the quality of the collected data. These activities occur at different stages of the data collection process beginning with the registry database development. These activities are embedded into registry development and data collection.

Reference: The National Cardiovascular Disease Registry (NCDR) Data Quality Brief

Hospital Registry Data Quality Process

All NCDR web-based data collection tools are created with data entry checks such as range checks, parent-child checks or date checks to ensure data consistency. With the option to upload from existing hospital systems, the NCDR also offers its participants a list of certified vendors that go through a rigorous process to assess compatibility, verify correct data transfer and ensure all NCDR export requirements are met.

Facility Training

The NCDR has established a strong hospital outreach and training system to support its suite of registries. This system includes a comprehensive orientation and continuing education program to address the educational needs of NCDR registry participants. Learn more about Training and Education.

Data Quality Reports

All data submissions are evaluated for errors (data assessment) and completeness (data completeness assessment). An automated summary report is sent to the participants after each data submission and participants may correct and resubmit their data (as needed) .

National Audit Program

The NCDR audit program, which includes hospital chart reviews and blind data abstractions, assesses the accuracy of the data and enables participants to identify areas for improved data entry. The NCDR also provides a mechanism for adjudication following an audit. In addition, there is an assessment for data completeness, ensuring that all patient data that should have been submitted to the registry, have been entered.

Regional Audit Program

The NCDR is partnering with several entities that conduct regional audits of selected NCDR Registries on behalf of states or hospitals consortia.

Self-Audit Program

To support participants' effort to submit accurate data, the NCDR offers a self-audit tool that enables participants to carefully review their data collection process.

Quality Process for the Outpatient Registries

The data quality processes for the PINNACLE Registry and Diabetes Collaborative Registry are designed to ensure accurate reporting while minimizing the data collection burden for participants. These processes include the following:

Data collection tool and software certification

Data collection from outpatient practices is based on the extraction of registry-specific data from existing electronic health records (EHR). Some practice EHRs require installation of system integration (SI) software used to map and extract the relevant registry data fields and transmit them to the PINNACLE Registry and/or Diabetes Collaborative Registry secure databases. Other practices may submit data using a file push from a certified EHR. Certified EHRs include the application service providers (ASP) or cloud-based systems that have demonstrated an ability to extract and submit data on behalf of participating practices. Learn more about the outpatient registries, EHR interfaces and data collection requirements.

Participant Reports

Once either the SI software or a data push interface is in place, data collection for the outpatient registries continues seamlessly without any further requirements from the practice. Participants in the PINNACLE Registry and Diabetes Collaborative Registry receive quarterly and monthly performance reports covering a series of measures and metrics. Additionally, the practice and its providers will have access to their own individual accounts from which they can update practice demographic information.

Data Audits

The NCDR audit program, which includes a review of randomly selected patient charts and blinded data abstractions, assesses the accuracy of the data and identifies areas for improved data submission.

EHR data are constantly changing. Software upgrades and practice business changes can change the data structure or system integration needs at a practice. When data anomalies are detected, a PINNACLE Registry or Diabetes Collaborative Registry representative will work with the practice, as needed, to make any required adjustments.

Temp Styles

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