What is NCDR?
The American College of Cardiology’s National Cardiovascular Data Registry (NCDR) is a suite of data registries related to cardiovascular care that helps hospitals, health systems, and practices measure and improve care outcomes. Individual registries for hospitals include CathPCI, Chest Pain – MI, EP Device Implant, STS/ACC TVT, LAAO, Afib Ablation, IMPACT, and PVI. Outpatient registries include PINNACLE and Diabetes Collaborative.
Table of Contents
- Best Practice #1: Stay Up to Date
- Best Practice #2: Build Rapport and Establish Stakeholder Buy-In
- Best Practice #3: Abstract and Submit Early and Often
- Best Practice #4: Achieve Optimal Abstraction Accuracy with a High-Quality IRR Program
- Best Practice #5: Thoroughly Understand the Data and Effectively Communicate Findings
- Behind the Trend Toward NCDR Abstraction “Smartsourcing”
Participating in the American College of Cardiology’s National Cardiovascular Data Registry (NCDR) generates a trove of clinical data that can help facilities better understand certain aspects of their performance and equip them to improve quality of care as well as measure performance, and demonstrate success in the process.
Standing up a comprehensive program involves more than just data collection. An investment is required to support these important registries and realize the desired results of increased evidence-based care and improved outcomes. But not all facilities’ NCDR programs are created equal. Both the quality and quantity of data produced from participating in the NCDR registry can vary dramatically from one facility to another, as well as how successfully the data is used to drive improvements.
With a decade of experience in specialized registry abstraction and management both as hospital staff and as an Account Lead for ADN’s Core Measures & Registry Data Abstraction Outsourcing Service, ADN’s top NCDR expert, Tammy Holton, shared 5 best practices for effectively managing your facility’s NCDR program.
Best Practice #1: Stay Up to Date
One of the most important aspects of leading a top-notch NCDR program is being knowledgeable and staying up to date. Because registries like NCDR are ever-changing, maintaining an up-to-date knowledge base is a foundational building block. Without it, a program will almost certainly topple. Moreover, many of the other best practices depend on and are made easier by a Registry Manager demonstrating expertise on the topic. Knowledge base items that need constant tending include program requirements, evidence-based guidelines, abstraction specifications, transmission standards and deadlines, dashboard updates, reporting and benchmarking options, and validation, as well as important announcements.
Staying up to date on all the educational offerings made available on the NCDR website is also beneficial. The QII Learning Center has an array of on-demand courses that range from very basic registry overviews to more in-depth topics like understanding Risk Adjusted Metrics. Other great resources available on the website are the frequently updated FAQs, the Monthly Case Scenarios, and the Registry Calls that are held every other month and are listed on the NCDR home page for the select registry. If you are unable to attend the registry call, it’s typically posted on the NCDR website a few days after the meeting. “One of my favorite features is the ‘Questions From Your Peers’ section of the calls,” Holton said. “Typically if you have lingering uncertainties, you’ll find you are not alone and there are others out there with the same questions.”
Best Practice #2: Build Rapport and Establish Stakeholder Buy-In
Building rapport and establishing stakeholder buy-in are make-it-or-break-it components to a successful NCDR program. Thus, the correct approach to achieving these critical elements is crucial. Taking the time and effort to help physicians (the primary stakeholder group) understand why your hospital is participating in the NCDR program and how their efforts will help improve overall care quality will pay dividends. “If you can get physician buy-in, you’re going to be golden,” Holton said.
“A lot of times we find the problem isn’t that something wasn’t done, but rather it wasn’t documented.” Physicians are notoriously busy. And without the right elicitation of buy-in, it may be distressing to have quality or cardiovascular team members continually approaching them about lacking documentation. But if the groundwork has been laid properly to communicate the “why” behind your efforts, these interactions will be much more fruitful. With growing emphasis on the domain of quality in healthcare, physicians are accustomed to receiving feedback and tend to show the greatest interest when they’re able to see how their clinical documentation is tied to the improvements. “Driving home the ‘why’ and making a compelling case with real-world examples can make things much easier,” Holton said.
“A not-so-successful strategy I’ve seen some facilities rely on is sending multiple emails requesting additional documentation, but not explaining why,” Holton said. Instead, she finds that holding a monthly cardiovascular meeting creates an ideal setting to make the case for your registry efforts. “You want to help physicians understand the rationale behind your requests and show how their changes can make a difference in the performance metrics.” In Holton’s experience, these meetings are met with some resistance initially; but, the providers eventually want to see their performance reports and begin to more actively track their progress.
(For additional tactics on working effectively with your physician stakeholder group, see Best Practice #5 below.)
Best Practice #3: Abstract and Submit Early and Often
Staying ahead of the ball is a critical aspect of a first-class abstraction program, and typically one that only comes with extensive experience. “Seasoned Registry Managers, and some savvy abstractors, make a point to proactively identify risks before they become full-blown problems,” Holton said. This involves speaking up about trends noticed during data abstraction and/or recognizing emerging patterns when reviewing specific types of outliers.
One of Holton’s most important recommendations is to submit early and often. “One of my first questions when we take on a new account is ‘How often do you submit your data?’,” Holton said. “Unfortunately, a lot of facilities wait until shortly before the deadline to submit. You should never wait until the end of the quarter or harvest period to submit your data because this can result in major data quality issues, leaving no time for re-abstractions and corrections. Submitting unclean data not only impacts your internal reports but also affects the integrity of the NCDR database. That’s why I always prefer weekly data submissions and aim to complete them by the end of the day Friday. The way the NCDR system works is that it aggregates all new data once a week on Sundays. So, Monday morning your dashboard is fresh with all the data you’ve submitted from the week before.” Then, based on the feedback reports, the Registry Manager can address any conflicts that are preventing case acceptance or re-abstract any elements that were flagged with informational errors. Additionally, teams can review internal performance gaps and initiate timely improvement plans. Spending this time each week makes the workload much more manageable.
The reason many facilities wait until the end of the harvest period is not due to a knowledge deficit by the Registry Manager, but rather a lack of time and resources. Most facilities don’t have the manpower to achieve early and frequent data reviews and are thus late to identify submission issues and opportunities to improve care compliance. By the time the Institutional Outcomes Report is released by the NCDR, it can be as much as six months after the discharges and abstractions. So you’re looking at problems that offer little in terms of relevance to your stakeholders. “The only way to prevent this is to constantly work the data. And most facilities don’t have sufficient time or staff to do that,” Holton said. “If you want to ensure accurate data and identify trends early on, my advice is to submit your cases every week and immediately address any areas of concern. That way you can avoid a last-minute crisis.”
Best Practice #4: Achieve Optimal Abstraction Accuracy with a High-Quality IRR Program
A key component to a successful NCDR program is making sure that you have high-quality abstractions. The best way to do that is to set up a stellar Inter-Rater Reliability (IRR) program. IRR requires a fellow team member to abstract a sample of the same cases that another abstractor has already completed and discuss any mismatches. Sometimes mismatches result from the original abstractor not knowing where in the documentation a key piece of information is located. Other times, it might be due to a misunderstanding of the abstraction definitions. “IRR is a worthwhile process because it prompts important discussions. It really is the best way to ensure reliable, consistent abstractions, which are the backbone of your clinical improvement efforts.”
Best Practice #5: Thoroughly Understand the Data and Effectively Communicate Findings
One of the main responsibilities of a Registry Manager is being able to understand the data, specifically which data elements impact your outcomes and the underlying rationales. Equally as important is the ability to effectively convey and present findings to your stakeholders.
Before preparing to present any information, ensuring you know the data inside and out is key. It is important that the Registry Manager and team can show how existing processes and practice patterns influence registry performance. To identify priority areas of focus, start by analyzing the Executive Summary Report, which includes your facility’s metric performance for the Rolling 4 Quarters (R4Q). Also included are a comparison group performance graph and a three-year historical performance graph so you can evaluate internally and against other NCDR database participants.
The next step is to drill down into your data to identify the highest- and lowest-performing physicians. One step further involves delving deeper into the case details to isolate the sources of variation. When working with ADN abstraction outsourcing clients, Holton noted that the Patient Level Detail Reports, which help quickly identify outliers, are a valuable tool. “A good Registry Manager will go into the chart to see why the case is an outlier in order to better understand where the breakdown occurred,” Holton said.
Using these Patient Level Detail Reports when talking with your physician stakeholders is a highly effective strategy. “Having patient names and not just numbers facilitates a much more productive stakeholder conversation,” Holton said. Moreover, this type of report elicits a healthy sense of competition, another valuable aspect of this strategy. “No one wants to be at the bottom of a drill-down report grouped by physician,” Holton said.
And last but not least, once you have a solid understanding of the data, organizing stakeholder reports into a visually appealing format that highlights clinically meaningful information is critical. “If you hand physicians a 10-page report with a list of names, they’re not going to take the time to try to decipher what it all means,” she said. “You have to figure out a way to make it digestible for them.”
Underlying the most successful NCDR programs is a strong communication system among the Registry Manager, stakeholders and abstractors. Such a system is key to effectively conveying to stakeholders overall facility performance, specific outliers, documentation needs, and negative and positive trends. And an equally important branch of that information tree is a productive line of communication with abstractors, ensuring they know what you want them to home in on and their responsibility to proactively speak up regarding opportunities.
Behind the Trend Toward NCDR Abstraction “Smartsourcing”
While many Registry Managers have the ability and knowledge to run a top-notch NCDR program, the all-too-common reality is that they simply don’t have the time given all the other duties on their plate. That’s why many facilities are moving toward “smartsourcing” the data abstraction and management duties so they are freed up to actually do more quality improvement work based on insights from their NCDR and other abstraction data.
Rather than having to constantly sift through the data among all their other duties, an outsourced partner can surface the key insights that warrant their time and attention. “We can point that out for them and make it easier,” Holton said.
Some facilities opt for partial outsourcing to free up some of their team’s time for more quality improvement work while others choose to fully offload the data collection burden to double down on PI projects. Both options also serve as a safety net for abstractor shortages from turnover, PTO and temporary leave, preventing backlogs from piling up during any absences as an outsourcing partner can easily shoulder the burden in the interim.
Aside from offloading time-consuming routine data investigation as well as the maintenance of an IRR program, below are the tactical and strategic reasons most facilities smartsource their data abstraction.
Take advantage of per-chart pricing to reduce costs, reallocate abstraction staff to frontline positions or other roles, then outsource those positions to shave budget dollars. Bundle with our Core Measures application to save even more.
IMPROVE BUSINESS FOCUS
Focus your time and energy on the key goal leadership expects of quality directors and managers: Building a High-Reliability Organization. Offload the time-consuming management of abstraction to expertly trained, skilled specialists.
Insourcing carries costs beyond salaries. Data shows the true cost per employee that includes benefits/taxes is 125% – 140% of the salary, not to mention soft/unknown costs and the manager’s time cost. Download the Outsourcing Cost-Benefit Analysis Template.
Abstraction is complex and time-consuming for your already stretched resources. Reallocate existing and scarce staff who are needed either to help in frontline care positions or to implement and monitor improvement tactics and initiatives.
SHIFT FROM GENERALISTS TO EXPERTS
Insourced teams typically rely on one or a few abstraction generalists who may also wear other hats. ADN’s team includes experts in many registries and measures who also stay updated on ever-evolving specifications.
INCREASE AGILITY & FLEXIBILITY
Reducing the need to manage abstraction allows your department to more quickly implement improvement strategies or adapt to risks and threats. Gain confidence, reduce overhead, keep headcount low, and leave data collection headaches to the experts.
ELIMINATE OPERATIONAL CHALLENGES OF TURNOVER AND LEAVE
Staff vacancies can be a real source of anxiety and frustration. An outsourcing partner provides an essential safety net for your department. Planned or unplanned departures, illness, vacation, temporary or extended leave are no longer a challenge by extending your department with an outsourcing partner.
PREPARE FOR FUTURE CHALLENGES
Prepare for future financial and operational threats like the current pandemic, as well as other challenges, by freeing up your time and budget to better plan and weather future events.
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