2015-2016 QC Activities Summary - University of Miami · 7/27/2016 STEVEN PEACE, CTR 1 2015-2016 QC...
Transcript of 2015-2016 QC Activities Summary - University of Miami · 7/27/2016 STEVEN PEACE, CTR 1 2015-2016 QC...
F C D S A N N U A L C O N F E R E N C EB O C A R A T O N , F L O R I D A
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S T E V E N P E A C E , C T R
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2015-2016 QC Activities Summary
Presentation Outline2
FCDS Data Quality Program
FCDS 2015 Submission Summary
FCDS QC Review Sample Summary
FCDS QC Review Summary Reports
2016 FCDS DQIR (2014 Data)
2016 NPCR Data Evaluation Reports
Surgery, NOS Codes
Sex Coding Errors – Again!
FCDS Data Quality Program - Goals3
Establish, perform, manage Quality Improvement/Quality Control projects
Apply national and internal standards for data collection, aggregation, etc
Systematically measure performance against those standards
Assess outcomes and performance measures
Develop measurement and evaluation tools
Develop quality enhancement strategies
Assess registry needs and satisfaction
Monitor completeness, quality and timeliness
Provide education and training to improve data quality
FCDS Data Quality Program - Methods4
FCDS Policy FCDS Abstractor Code Requirement FCDS EDITS Requirement Text Documentation Requirement Deadlines and IT Security
FCDS Procedures FCDS IDEA – Communication/Transmission FCDS Internal Data Processing Monitoring FORCES/CORRECTIONS/DELETIONS Patient and Tumor Linkage & Consolidation
FCDS Monitoring / Audits Audits for Completeness Audits for Timeliness Audits for Accuracy
FCDS Data Quality Reports Quarterly/Annual Status Reports QC Review Summary Ad Hoc Reports Audit Results
Submission Summary & QC Review Sample5
Description # Cases % of TotalTotal Cases Submitted to FCDS 1/1/2015-12/31/2015 – All Sources 224,356 100%Total Cases – NO CHANGE – Pass ALL Edits – No Visual Review by FC or QC 210,574 93.9%
Total Cases – FC Visual Review (FC Review to assess case for possible FORCE) 13,708 6.1%• FORCED (EDIT Override Confirmed and FORCE was set - NOT an error) 4,598 2.0%• CORRECTED (1 or more corrections made based on text – NOT a FORCE) 6,750 3.0%• DELETED (duplicate case, not a reportable neoplasm, not a new primary) 2,360 1.1%
Total Cases – Every 25th Case QC Review Sample/Visual Editing
10,308 4.6%• Sample includes 4% of analytic hospital, radiation, surgery center cases• Sample includes ALL male breast and ALL pediatric cases • Sample does not include dermatology or other physician office cases
Total Cases Visually Edited by FCDS in 2014 (combined FC and/or QC Review) 24,016 10.7%
QC Review Sample / Visual Editing - Summary6
Description # Cases % of TotalTotal Cases – Every 25th Case QC Review Sample/Visual Editing 10,308 4.6% of All Cases
Total Cases – NO CHANGE on QC Review 7,118 69.1% of QC SampleTotal Cases Sent to Facility with Correction or Inquiry 3,190 30.9% of QC Sample
Total Cases Sent to Facility with Correction or Inquiry 3,190 30.9% of QC Sample• NO CHANGE after Follow-Back to Facility 794 24.9%• FORCED (EDIT Override Confirmed - NOT an error) 46 1.4%• CORRECTED (1 or more corrections made – NOT a FORCE) 2,309 72.4%• DELETED (duplicate case, not a reportable neoplasm, not a new primary) 41 2.3%
AHCA In-Patient: Follow-Back Analysis7
AHCA Ambi: Follow-Back Analysis8
QC Review Summary Report9
QC Review Summary Reports10
QC Review Summary Reports11
2016 FCDS DQIR (2014 Analytic Cases)12
Sample Report
2016 Call for Data – NPCR DER Report13
2016 Call for Data – NPCR DER Report14
2016 Call for Data – NPCR DER Report15
2016 Call for Data – NPCR DER Report16
Overuse of Surgery NOS Codes17
Sex Coding Errors18
Unusual first names
Increase over past 5 Years
Registrars still not checking
Edit Failures will be checked and validated.
Easy for Reproductive Cancers but not Colon, Lung, etc.
FCDS is borrowing methodology from New York and Alaska that will validate common first names by decade.
Questions19