Wooster Community: Using Data Validation to Detect Quality Measure Errors

Reporting of both abstracted & electronic data from a single solution to better monitor the status of measures and identify the cause of anomalies.

The Challenge
CMS recently mandated submission of 4 of the 28 available electronic quality measures (eCQMs) for hospitals to fulfill part of their Inpatient Quality Reporting (IQR) program requirements. The team at Wooster Community Hospital understood the significance of this change and implemented a process to validate, monitor and ultimately improve their eCQM results long before this requirement.

In the initial review, Karen McLaughlin, Clinical Systems Analyst at Wooster Community Hospital, discovered that more than half of the 16 eCQMs had performance rates below 50% and the results were not in alignment with the abstracted measure results. “A few of them were even at zero,” said Karen. “Obviously, there was a problem.”

The Solution
Wooster had implemented Medisolv’s ENCOR quality reporting and management solution for both electronic and abstracted quality measures. Using the advanced features of the applications, they were able to review and compare measures side-by-side in the shared dashboard tool. They easily identified significant gaps between the eCQM results and their abstracted counterparts.

Karen’s approach was to first evaluate and troubleshoot the measures with the most significant differences in performance rates. She then identified several patients that were failing the electronic measures (and passing the abstracted) and spent time reviewing their clinical documentation in the EHR. In doing so, she confirmed that for the patients in question, the appropriate documentation had in fact been completed.