Welcome to Lesson 2 of 2 of this learning activity titled Data Quality Report, DQR, Quality Assurance and Workflow. Upon completion of this two-part learning activity, the learner should be able to identify which elements are reported to the registry, apply a systematic approach for the data quality report navigation, and identify the quality assurance process in the data quality report. What are DPIs? DPIs are direct patient identifiers. The identifiers included are last name, first name, middle name, zip code, social security number, and HIC or MBI number. It's the facility's choice to submit patients with or without DPIs. If unsure how to submit your facility's patients, please refer to your facility's policy. If data is being submitted without DPIs, the exclusion of DPIs can be done at the patient level as well as the submission level. To exclude the DPIs for a specific patient, please click on Exclude DPI when entering the patient's demographics. To exclude the DPIs for all patients within a submission, please choose Submit to DQR without DPI when submitting data to the DQR. If your facility participates in a registry with a CMS mandate, which at this time are LAAO registry and TVT registries, please keep in mind that CMS will need to be able to confirm Medicare patients have been submitted to the registry in order to meet the requirements of the National Coverage Determination. Please consult with your local CMS representative for more information. After submitting your data to the DQR, the system will display your data being processed by displaying your submission status as MQ. After your submission has been processed, the system will direct you to the Submission Status page. This page lists all of your facility's submissions. To view your submission's final result, please click the View Submission Results tab to be directed to the DQR page. The DQR page will display all of your facility's submission information. It can be viewed by All Submissions, Submitted Today, Submitted in the Last 7 Days, or you can choose a specific quarter. For registry submitting follow-up data, you may also choose to see only base or follow-up submissions. The DQR page will display all of the information necessary to follow your submission history. Every submission will provide 9 or 10 elements of information. The information will start with the quarter being submitted, the date in which the data was received, the vendor used, this could be the ACC or a third-party vendor, the transaction number, and the number of patients included in the submission. Additionally, this will include data assessment, the completeness assessment, the benchmark inclusion status, the population status, and for the registries who submit follow-up data, submission type, which will be either base or follow-up. Every submission will undergo a data assessment as well as a completeness assessment. If the submission fails the data assessment, it means the submission has been assessed and does not pass the NCDR checks. The submission will also receive a red benchmark inclusion status. In order to see the errors preventing the submission from passing the data assessment, please click on the fail highlighted in blue. The system will direct you to the submission results data assessment page. This page will display the errors causing the failed data assessment. The errors will be listed and will provide the data's NCDR ID, other ID, last name, arrival date and time, procedure date and time, the discharge date, error type, error code, and a description of the error. This information can be downloaded as an Excel file or printed for reference while fixing errors. Once we have found the errors causing the failed data assessment, the data will have to be changed or new data added. To change or add new data, we will direct ourselves to the data collection tool and access the episode search and edit functionality. Once we access the episode management page, we can search for the patient by entering the patient ID number and or any other patient identifier. After entering any patient identifier, please click search. After clicking search, the patient will be displayed in the bottom of the screen. To gain access to the patient's procedure information, please choose the edit icon which resembles a notepad with a pencil. If the patient has multiple episodes of care under their name, please make sure the right episode of care is chosen to be edited. After the changes or new data have been entered, please make sure that new data is saved, a quality check is performed, and the data is resubmitted to the DQR. If the submission does not pass the completeness assessment, meaning that not enough data was provided to pass the NCDR checks, the submission will be given a yellow benchmark inclusion status. To find what data was not provided, please click on the failed highlight in the blue. The system will direct you to the submission results completeness assessment summary page. This page will display the data that was incomplete and caused the completeness assessment to fail. The incomplete data or elements will be listed and will provide the patient's NCDR ID, other ID, composite, arrival date and time, discharge date, sequence number, element name, and element status. When the element status is shown as failed, it means the specific element was left blank and not coded. This information can be downloaded as an Excel file or printed for reference while fixing errors. The composites and element thresholds can be found in the DQR companion guide document, which is located under the documents page of the resources tab. Once we have found what data is missing and causing the failed completeness assessment, the data will have to be added. To add new data, we will direct ourselves to the data collection tool and access the episode via search and edit functionality. Once we access the episode management page, we can search for the patient by entering the patient ID number or any other patient identifier. After entering any patient identifier, please click search. After clicking search, the patient will be displayed in the bottom of the screen. To gain access to the patient's procedure information, please choose the edit icon which resembles a notepad with a pencil. If the patient has multiple episodes of care under their name, please make sure the right episode of care is chosen to be edited. After the data has been entered, please make sure that new data is saved, a quality check is performed, and the data is resubmitted to the DQR. When the submitted data passes the data and completeness assessments, meaning the data has passed all NCDR checks for quality and completeness, the data will receive a green benchmark submission status. The benchmark inclusion status indicates if the submission is included in the National and or Comparison Group benchmarks. When the data passes the data and completeness assessments, it ensures that the submitted data is included in the Executive Summary metrics. It also ensures the inclusion of the data in quarterly aggregations that make up the National and Comparison Group statistics. The benchmark report is still provided if submissions fail the data or completeness assessments. However, your facility's data is not a part of the National and Comparison Benchmark aggregation. A red status means that your submission failed the data assessment and a completeness assessment could not be performed. The data is not received by NCDR and will not be included in the outcomes report. A yellow status means that your submission passed the data assessment but failed the completeness assessment. This data will not be included in the outcomes report, registry aggregate, or the Executive Summary metrics, but will be included in the details section of your facility's outcomes report. You will not be able to compare your facility with hospitals in your volume group or all hospitals participating in the registry. A green status will assure the data submitted will be included in the Benchmark Report Registry National Aggregate and in the Executive Summary metrics. Always go for green. This concludes this learning activity titled Data Quality Report, DQR, Quality Assurance and Workflow. Thank you for your participation.

Data Quality Report

Quality Assurance

Workflow

Direct Patient Identifiers

Medicare patients