DQA Methodology
Preparatory Work
- Sample of episodes are extracted from the national database for the hospitals we plan to assess. For each hospital, the period sampled is the three most recent months for which submission to the national database is substantially complete. To ensure the required number of records are available for the assessment the sample is twice that required.
- Pre-assessment meeting held with the hospital contact so that all relevant information, issues and hospital requirements can be considered.
- Case-lists are sent to the hospital for the records needed during the assessment
Assessment Process
- DQA staff compares the data in the sample against the information held in the medical record for the relevant episode.
- Any errors are identified and described using a series of standard error types. Further information on each error is also recorded using data item messages, which specify where the information was found in the record and whether the information was available to the coders.
- On completion of the assessment DQA staff discuss each clinical coding error (and supporting evidence) with members of the coding staff and agree any actions required.
- Error Type Definitions
- DQA source documents and document information availability types
- SMR01 data items and DQA abbreviations
- SMR02 assessed data items
Confidentiality
- The "Confidentiality Rules for ISD Scotland Staff" are applied in the handling of all patient identifiable data. Supplementary to these rules, the team have their own procedures/rules designed to cover work in hospitals. In addition the team will adhere to all hospital confidentiality procedures/rules.
Reporting
- All data collected is cleaned to ensure consistency in the application of the assessment criteria. The data is then analysed and results produced.
- How accuracy rates for clinical coding are calculated
- A draft report is produced and sent to the hospital contact for comments.
- Any changes are discussed, actioned and a final copy of the report is issued to the Board and Divisional Chief Executives, Caldicott Guardian (and Medical Director if different) and Medical Records Manager for the relevant hospital.
- An amendment report detailing all episodes where an error was found by DQA is sent to the hospital contact to allow for the amendment of the hospital record and resubmission to the national database.
Scotland Report
- All findings from each individual hospital in the project are merged and Scotland average figures are produced for the data items assessed.
- Scotland report is produced and sent to the Board and Divisional Chief Executives, Caldicott Guardian (and Medical Director if different) and Medical Records Manager for the hospitals assessed in the project. It also has a wider circulation to the Scottish Executive, colleagues in ISD, CPHMS and is published on the web.
