Welcome to Part 4 of an NCDR Overview. After participation in Part 4, the learner should be able to identify how NCDR ensures quality, locate NCDR resources, and identify benefits of participation with NCDR. Ensuring quality is an important goal to the overall creation and maintenance of NCDR Registry products. To maximize the quality of NCDR products, many layers of quality assurance processes take place. For the purpose of this education, we will divide NCDR Registry quality processes into three categories, Pre-Data Capture, Data Submission, and Post-Data Capture. This slide focuses on Pre-Data Capture, and the processes to ensure quality within NCDR products. System Acceptance Testing, SAT, is performed for all new registry products and product upgrades. The purpose of this testing is to evaluate the existing NCDR system with all new projects with business requirements and compliances to assess whether it will be acceptable for delivery. User Acceptance Testing, UAT, follows SAT and includes NCDR staff testing of all applications of the business requirements to ensure bugs are identified and or to provide feedback for the new product or product upgrades. After SAT and UAT is completed, Beta Testing is considered the last stage of testing. Beta Testing normally involves distributing the product to NCDR participant beta test sites and individual users, beta testers, to obtain real-world exposure and feedback. The QI process is a necessary component to ensure that the product received by NCDR participants works and works well. After testing is completed, training and education for new products and product upgrades will be initiated by our teams of registry experts, who provide valuable information and updates to our NCDR participant community. Clinically experienced support staff are easily accessible to NCDR participants via Contact Us functionality on our website. Quality Assurance is also built into the NCDR data entry and submission processes for every hospital-based registry. All data entered into the data collection tool must pass through the quality check process first before it can be evaluated by the data quality report process. So what is the quality check process? It's functionality within the data collection tool which provides an initial assessment of logic and accuracy for the data entered. Quality check process identifies errors and outliers in data before it has a chance to be sent to the data quality report process, which is then harvested by NCDR's data warehouse. Every individual patient data collection form must pass through the NCDR quality check all errors identified by this quality check process must be corrected in order to advance to the data quality report submission process. So what is the data quality report? It's functionality which provides two additional layers of data assessment based on thresholds as well as additional levels of logic and accuracy. The intent of the data quality report is to ensure the data eligible for benchmark reporting is of the highest quality possible. Data quality for every submission is tagged with a red, yellow, or a green status which will determine its inclusion in registry aggregations and outcomes and metric reporting. Ensuring NCDR data registry quality also includes post-data submission. Submitting information focuses on NCDR's national audit program, self-audit program for our NCDR registries, and NCDR's data outlier program. NCDR maintains an ongoing audit program for all of its hospital-based registries. Participating NCDR hospitals are included in the randomized selection of hospitals each year. Audit is performed by an external vendor and consists of an evaluation of the data submitted to the registry compared to the medical record provided by the hospital for the audit. Subset of data elements are evaluated and the data included in the audit are from the previous calendar year. Self-audit tool is another method to evaluate the accuracy of the registry data. The purpose is to assist NCDR participants in conducting an internal review of their data. It is set up in Excel and this tool allows the hospital to choose the variables that are of interest to them and select patients for evaluation. Different staff members may then enter the data into separate worksheets and based on the entries of the two individuals, the tool provides feedback on data consistency and highlights data elements which may need further discussion. The goal is to facilitate review of critical data elements or identify problematic fields and improve the data quality. As an added benefit, this tool could also be used for training purposes to evaluate coding consistency and interpretation amongst registry staff. Other aspect of data quality includes programmatic review of data through NCDR's Data Outlier Program. Through oversight from registry steering committees, product managers, NCDR data analytics, and NCDR data quality teams, data outliers are identified. With the intent of data quality at the forefront, NCDR creates data outlier reports which are executed throughout the year and remain as an ongoing process. Once a participant is identified on a data outlier report, the report is provided to the hospital via file delivery. The purpose of the outlier report is to flag hospitals whose data do not appear to conform to what is expected with the goal of encouraging process modifications or other QI initiatives. NCDR resources are available to all registry participants from day one. Participants have access to a wide variety of helpful orientation and learning resources such as the QII Learning Center, resource documents, registry calls, including questions from your peers, dynamic dashboards, case scenarios, NCCD Quality Summit, and a whole lot more. Make sure to navigate through the website to locate all the materials and resources available to you which will lead you towards success. A variety of resource documents are available for every registry and sorted into categories for convenience. Documents include all the information necessary for participants to be successful and provide materials to begin registry learning on day one. The QII Learning Center is a valuable resource for NCDR participants. The QII Learning Center is designed to provide online educational opportunities through a variety of queues such as CE options, non-CE options, case scenarios, Quality Summit presentations, and accreditation education. Make sure you take advantage of the continuing education credits when you complete each course under the CE options track. CE credits are added to the Learning Center on an ongoing basis and are available for all of NCDR's suite of data registries. Registry calls are provided for our participants throughout the year to provide an ongoing education via questions from your peers. In these sessions, you will be able to review questions submitted by your registry peers along with the answers and rationale. Call sessions are led by the Clinical Quality Advisor team. You can schedule by navigating to Resources and Registry Calls in the left navigation bar within each registry. Information is posted on the registry announcement pages prior to the date of each call. Meeting minutes are provided for each of these calls afterwards. Dynamic case scenarios are added to each registry website and can be accessed through the QII Learning Center. Scenarios allow the participant to connect to a real-life registry-specific scenario to experience how that information from the scenario would translate into the registry by inputting it, what it looks like in outcomes and metrics, and more. Dynamic dashboards allow the ACC's NCDR participant to perform close-to-real-time data review and quality metrics and performance measures, plus a lot more. Participants can drill down to patient details on data which is updated weekly to allow for the most up-to-date review of their data. The annual Quality Summit provides participants with NCDR registry-specific and hospital industry knowledge, plus a deeper understanding of the value of accreditation and ways patient data can drive process improvement initiatives. NCDR's DUS functionality is available for all NCDR participants. If you need to contact NCDR for any reason, simply fill out your name, email, phone, registry of interest, and request a detailed description of your question. NCDR Business Support Operations and Clinical Quality Advisor Assistance is available during regular business hours Monday through Friday from 9 a.m. to 5 p.m. Eastern Time. All inquiries are answered in the order they are received. Benefits to participating in ACC's suite of data registries. We believe in the NCDR mission to improve patient care and heart health through trusted, real-world evidence. We believe in a world where NCDR advances patient care, outcomes, and value through knowledge and innovation. We believe the benefits of registry participation are leading the way to a world where innovation and knowledge optimize cardiovascular care and outcomes. A variety of summary and registry metrics, along with patient-level detailed reports in our dashboards, provide valuable feedback on performance measures, quality metrics, process metrics, outcome metrics, utilization metrics, appropriate use criteria metrics, and a lot more. Reports are aggregated and published using the highest quality data which has been processed and evaluated by our quality check process and data quality review process. Patient-level detailed reports in our dynamic dashboards allow the user to review data refreshed on a weekly basis. Dashboards provide a near real-time view of executive summary metrics, patient-level drill downs, and comparison filters. Comparisons are available for each facility to provide a realistic view of hospital performances when compared to like-volume groups as well as to a national benchmark aggregate. Our dashboards provide a functionality where physician-level data can be reviewed. This reporting tool uses the physician MPI number to generate specific reports based on procedures performed by the physician and then submitted by the CAHP PCI Registry Participating Hospital. The dashboard may be used for quality improvement purposes, internal reporting, and for self-directed performance improvement modules for physicians. Our dashboard toolkits through Quality Improvement for Institutions are easy-to-use tools which will help you implement guidelines-based care and better practice care as well as address common clinical issues at your facility. There are many opportunities within ACC and NCDR to obtain a variety of continuing education credits. CEE, MOC, COP, MEE, and CEE are all available for a variety of product types. These credits may be earned at the ACC Quality Summit as well as through the NCDR loan. Communication in the ACC's NCDR registries also provides a valuable as well as a necessary way for facilities across the nation to meet state, federal, and payer requirements. NCDR's experience support staff are easily accessible to NCDR participants via Contact Us located on our registry website. NCDR registry participation supports ACC accreditation services programs. Learn more about accreditation services by navigating to our Quality Improvement for Institutions website at cvquality.acc.org. Thank you for participating in this learning activity titled, An NCDR Overview, Part 4. After participating in this learning activity, the learner should now be able to identify how NCDR ensures quality within NCDR resources and identify benefits of participation with NCDR. Thank you for participating in this learning activity titled, An NCDR Overview, Part 4.

NCDR education series

quality processes

Pre-Data Capture

Data Submission

Post-Data Capture