Abstract TP98: Data Quality Review: Opportunities Through Transparency

Abstract

Background: Manual abstraction is still the leading source of registry data entry. Due to variability, information should be reviewed for accuracy. Clinical processes that impact quality of care and hospital metrics are abstracted and entered in the Get with The Guidelines® (GWTG) suite of registry programs. GWTG data is intended to be abstracted in accordance with specified coding instructions with high integrity. Created in 2023, the Data Quality Review Program (DQR) reviews the medical record concurrently with abstracted GWTG data to help streamline processes and ensure accuracy of data entry. The information is then compiled to form an inner-rater reliability (IRR) report including performance improvement opportunities. Methods: Site participation is voluntary and a percentage of annual charts is selected. Records in GWTG are compared to corresponding patient records via screen sharing for accuracy. Discrepancies and opportunities are reviewed with each case including clinical pathway performance, regulatory standards, and coding elements. Chart review includes data used for GWTG achievement and quality awards, time-sensitive activities and social disparities of health. IRR is further supported by individual risk and occurrence factors for each element reviewed along with a total composite IRR score guided by a standardized framework. Results: From April to July 2023, 50 hospitals have completed the DQR. Sites have varied geographically, in intervention capabilities, and accrediting body. Sites completed an experience survey after the DQR using Likert scale and narrative questions. 100% of survey respondents rated the DQR a 5 the top score, and valued evidence-based education and discussion of site abstraction processes. DQR reports were presented during regulatory body surveys in 6 cases which resulted in “no findings” note in this component for the site. Conclusion: While abstraction is not directly related to clinical care there are opportunities to connect registry data entry to improvement, both in quality and delivery of care. Sites participating in the DQR feel better prepared for certification, validation of current practices, and enhanced knowledge of coding instructions demonstrated through quality matrix recommendations.