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Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, August 21, 2015 Posted in: Inpatient Rehab

Although I believe you can never have “enough quality,”  health systems that report outcomes to various agencies have much duplication and extreme amounts of manual abstraction of records. I was fortunate to have my eyes opened on a special project I worked on several years ago in Ohio to help a health system get their arms around data within their system in regards to time tables, data type, purpose, accountability and costs related to measurement and monitoring of information. The list was alarmingly long with much duplicate reporting required.

In this day of health care reform, with greater emphasis on measurement and management of outcomes, the first step to knowing how you are doing is to first get a glimpse of exactly what your hospital collects.  The who, what, where, when and why of data collected in your organization must be understood.  What is the goal and purpose of the data? Do you know exactly what is duplicated and shared to various outcomes agencies or insurers? Most important, what is the internal process of acting on the data and putting a process in place that provides appropriate feedback and adhesiveness to the expected protocol? Collecting data in and of itself is worthless. The end gain is managing the expected outcome and then rigidly applying and adhering to the standards that create the best outcome for patients and employees.  After all, this is the foundation for quality improvement.

From personal experience, the cost of data collection with so many expectations must be harnessed. Whenever possible, abstracting data directly from electronic charting with discrete elements available as a report is ideal. Letting technology work for you will be the sum gain for working smarter and not harder. It takes more than a small army to stay on top of so much work. Work that must be accurate and representative of the care you provide and take pride in performing is worth understanding and managing more accurately.

In alphabetical order, let me present a glimpse of what a small quality performance department juggled on a daily basis. Many required duplicated data for Process of Care reports (CMS required CORE Measures). This hospital did a full inventory for quality to find out exactly where it took place within their organization and ultimately where the data went. These reported below were in addition to their internal risk management incident reporting processes, although some of that data would be included in the measures sought by these various organizations.  Where available Web references are included.

  1. AHA                             American Hospital Association                                AHA.ORG
  2. AHRQ                          Agency for Healthcare Research & Quality
  3. ANTHEM                   Anthem Blue Cross & Blue Shield                    
  4. DELTA GROUP         Delta Group                                                             
  5. DELMARVA              Delmarva                                                                  
  6. HCAHPS                      (To Quality Net)                                                       (CMS)
  7. HOPQDRP                   (To Quality Net)                                                               CMS
  8. HQA                              Hospital Quality Alliance(NQF type reports)
  9. IHI                                Institute for Healthcare Improvement          (National Patient Safety Goals)
  10. ICPA                              Infection Control Prevention Assoc            
  11. ISO 9001                    (Initial stages of preparation per manuals)
  12. KePRO                          Ohio Medicare Quality Improvement Org  
  13. Leapfrog                      Leapfrog Group                                                      
  14. LogiCare                      Internal Data Base Emergency Dept              
  15. MedPar                        Medicare Provider Analysis and Review     
  16. NCDR-ACTION          National Cardiovascular Data Registry       
  17. NDNQI                         National Database Nursing QualityIndicators
  18. NEOHQC  OPSI          NE Ohio Hospitals Quality Collaborative     
  19. NPSG                             National Patient Safety Goals                           
  20. ODH                               Ohio Department of Health                               
  21. ORYX                            National Hospital Quality Measures                       approved vendor (
  22. QAE                               Quality Assurance Entry Reports (MIDAS)
  23. QualityNet                  Quality Net Exchange Data Warehouse       
  24. RHQDAPU                   Reporting Hosp Quality Data Annual Payment (to KePro CMS vendor)
  25. Specialty cert. TJC  Various programs, stroke, diabetes etc.     
  26. STS                                  Society of Thoracic Surgeons Registry      
  27. UHC                               United Healthcare                                                
  28. VHA  (& VAH SPI)   Voluntary Hospital Association                    


Take this challenge and create your own Quality Improvement Database query. See who and how they manage data. Discover your reporting frequency requirements and accountability to meeting those schedules. Find out how much you budget for each department to perform and/or pay for data submission. Who is authorized by vendor for uploading data and does it require a digital certificate to upload? Roll all this information into one report. Ask yourself; Is there too much quality these days? Quality is here to stay and to our fortune or misfortune will continue to be transparent.  Take the time now to understand and develop the plans necessary to be sure that the information you share is of true quality. Healthcare reform demands value and quality. Take the first step towards both.

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