Welcome to Lesson 1 of this learning activity titled, What is a DQR? Rationale and Training. The content in this lesson was developed by Claire Segawa and Fernando Garcia-Barbon. I'm David Bonner, and I'll be narrating this lesson. The course objectives are to demonstrate the importance of the participant's role in the data quality report, apply a systematic approach for data quality report navigation, and identify the quality assurance process in the data quality report. The Data Quality Program's goal is to validate the completeness, consistency, and accuracy of the data collected by the registries. The NCDR values quality and endeavors to ensure that the data used provide an accurate representation to allow for appropriate conclusions to be drawn. Data quality is important to the ACC and NCDR because the analyses and results from NCDR registry data are used for research and influence decision-making for public reporting, risk models, and appropriate use criteria. The three key components include completeness. All required elements are reported to the registry. This means that based on the data collection form, if the data are available, they should be submitted to the registry. Consistency. This has two concepts. The first one, everyone who handles the data shares a common understanding of the data and their definitions. The Data Dictionary provides definitions to guide data collection, and only those data meeting the criteria specified in the Data Dictionary should be entered. And the second, the data are logical, in that they are internally consistent. For example, the procedure date must be after the patient's date of birth. And then finally, accuracy. The data represent what is occurring at the facility. We expect that the data submitted to the registry reflect what occurred during the episode of care and documented in the medical records. The work to ensure good data quality begins well before any data are ever collected. NCDR data quality activities vary by the data collection phase. We view this as three phases, pre-data collection, which is the development and preparatory work to guide data collection, the data submission phase, when participating facilities actively submit their data to the registry, and the post-data submission phase, where evaluation of submitted data is done. The data quality report, which is the focus of this module, is part of the data submission phase. The data quality report allows for real-time assessment of the data upon submission and focuses primarily on completeness by setting thresholds for data entry and consistency by providing an evaluation of logic and internal consistency. What is the DQR? DQR stands for Data Quality Report, which is the process for submitting data files to NCDR. All submissions are passed through this process and are evaluated for errors and completeness. How do participants submit their data in order to be assessed by the DQR? There are two pathways participants can use to submit their data. The first one is the ACC web-based data collection tool, or the second way is a third-party software vendor who has been certified by the NCDR. Not all third-party vendors are available for all registries. After the data has been submitted and assessed by the DQR process, the data will be given a benchmark inclusion status of green, yellow, or red. We will discuss inclusion status in more detail later in this presentation. Here is a DQR workflow chart that can be very helpful in understanding the DQR process and steps. This chart is part of the DQR companion guide document, which is available for all registries and can be found under the Resources tab in Documents. The first step in the DQR process is to enter the data and complete the quality checks. The data will be entered through the NCDR data collection tool or a third-party vendor tool. The NCDR data collection tool is located under the Data tab. After entering the patient's data, please click Save or Save and Next at the bottom of the page in order to save the data entered. Save will just save the data. Save and Next will save the data and take you to the next page of the data collection tool. After saving the data, a quality check must always be performed. Quality check is part of the data collection tool submenu located to the left of the screen. The quality check process helps to identify errors prior to submitting data. Quality check will only evaluate data that has been entered and will not evaluate missing data or elements left blank. The quality check process will identify errors based on severity. Errors with an error severity of Warning and a category of Outlier will not affect the submission of data. With outlier errors, the system is only warning the abstractor of a value not meeting the usual range. If the value entered is correct, no changes need to be made. Errors with severity of Error and category of Selection, List, or Date will affect submission of data and need to be corrected before submitting the data. If errors are not corrected, the submission will result in system alerts or a failed submission. When the data has passed the quality check process, it is ready to be submitted. Data submission will be done through the Maintenance page or the Submit to DQR tab. The data will be submitted to the DQR with DPIs or without DPIs. DPI stands for Direct Patient Identifiers. More details on DPIs will be covered later in the presentation. Data that have passed the quality check can be submitted through two different pathways, depending on the registry product being used. The first pathway is through the Maintenance page, which is a part of the data collection tool. The second pathway is through the Submit to DQR tab located under Data. Both pathways will show the same information and follow the same process. The only difference is the location of the page. Submissions that have no system alerts are ready to be submitted and the system will allow you to choose the quarter to be submitted. If the quarter has system alerts, the system will not allow you to submit the data. When attempting to choose the quarter for submission, the system will show a stop sign when hovering over the square. To access system alerts in order to correct them, please click on the highlighted number under System Alerts. In this case, the highlighted number is 2. After clicking on the system alert number, the system will direct you to the Episode Management page and will display the patients having system alerts in the bottom of the page. In order to find the errors causing the system alerts, we'll need to access the patient's episode information by clicking the Edit Procedure icon. After accessing the patient's procedure information, we will perform a quality check in order to identify any errors. After all errors found by the quality check have been cleared, the system alert will resolve and data will become available to be submitted. Please make sure that the new data entered, or the fixed data, is saved prior to performing a quality check. An important factor to remember is that the system will issue system alerts to data that have not gone through the quality check process, making resolving some system alerts as simple as running a quality check. After all system alerts have been resolved, the quarter will become available to be submitted. After choosing a quarter or quarters to be submitted, please choose to submit with or without DPIs. These options are located at the bottom of the page. For more information, please visit www.cdc.gov.

DQR

data quality

registry

data collection

ACC web-based data collection tool