Introduction Prior to October 2017, our data management team was housed in a separate hospital department that operated from a different site on campus. This made it challenging for the two data managers to ask questions of BMT staff and providers, develop relationships, or understand the transplant process and its accreditation. Furthermore, because none of the leadership in the external department had BMT experience, the data managers were not properly trained, nor was their work sufficiently monitored and audited. To compound these problems, the BMT program was growing rapidly and increasing its transplant numbers by approximately 10-15% each year, thus increasing the CIBMTR reporting burden. These circumstances led to the failure of the 2017 CIBMTR audit, which prompted a complete restructuring of the data management team. Objective Establish an adequately staffed data management team with a team supervisor, implement formal data management training, develop an internal audit process, and collaborate with program leadership and the quality manager to ensure compliance with all CIBMTR requirements and FACT standards. Methods In response to the failed audit, the data managers transferred from the outside department to work directly in the BMT clinic and a data team supervisor was hired. The data supervisor collaborated with the program quality manager to develop a process for monthly internal data management audits. In addition, they created a formal training manual and competency checklist for the data manager role. The program now conducts extensive on-board training for data managers and ongoing weekly Q&A sessions to review results of internal audits, new/revised CIBMTR forms, or provide training, etc. To help with some of the more challenging CIBMTR fields, the team developed several physician worksheets, as well as a reference packet with response criteria and disease status guidelines from the CIBMTR Manual. Utilizing findings from CIBMTR and FACT, internal audits, and the results of CIBMTR's Best Practices Survey, the data supervisor and quality manager worked with the BMT medical director and nurse manager to request an additional data manager position. Working together, we successfully demonstrated the connection between CIBMTR compliance and FACT accreditation, including the potential negative impacts on our hospital if we did not appropriately staff and support our data management team. Results The changes we have made have led to consistently low error rates in internal data management audits. For the 6-month period from March 2019-August 2019, our cumulative critical field error rate was 1.79%, down from 5.3% in our 2017 CIBMTR audit. Conclusion Through a synergistic effort, the data supervisor and quality manager utilized the findings from our failed CIBMTR audit and its potential impact on FACT accreditation to expand and significantly improve our data management team.
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Aug 1, 2023
Akesha Edwards + 6
Open Access