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Page last updated: 25-SEP-2007
Hospital Data Quality
Statistical Publication Notice
25 September 2007
Towards Better Data from Scottish Hospitals: An Assessment of SMR01 and Associated Data 2004 - 2006, Scotland Report September 2007
INTRODUCTION
This project has collected and examined patient data from over 5000 patient records over a two year period from 2004 - 2006 covering 38 acute hospitals across Scotland. The report contains findings on the quality of information recorded at hospital level for selected data items for both Scotland and for individual hospitals.
KEY POINTS
The report shows that there has been a very steady accuracy rate of around 88% for Main Diagnosis and this has been the case for the past fifteen years. The accuracy rate for Main Operation has ranged between 91% and 95%.
When groups of codes for specific diseases such as coronary heart disease are grouped together the group accuracy rate is much higher than the national average accuracy rate of 88%.
INTERPRETATION
SMR01 records (patient hospital data returns produced on discharge from hospital) are analysed for a wide range of purposes, including medical research, clinical governance, epidemiology, performance management and resource allocation. It is important for users of SMR01 data to be aware of the level of accuracy in recording when using the information generated from such databases and ISD therefore monitors the accuracy levels by undertaking routine quality assurance assessments and publishing the results. For the vast majority of analyses of SMR01 the data are fit for purpose in producing summary statistics.
DETAILED FINDINGS
The overall accuracy of Main Condition coding was 88%. This figure is similar to the results from four previous SMR01 quality assurance assessments.
42% of hospitals achieved or exceeded the 90% recommended minimum target level for accuracy of Main Diagnosis.
The accuracy of Main Operation has decreased by 2% from 95% to 93%. It does however exceed the 90% recommended minimum target.
89% of hospitals achieved or exceeded the 90% recommended minimum target level for accuracy of Main Operation.
A new analysis of Main Diagnosis and Main Operation coding for a number of defined groups of disease codes (e.g. coronary heart disease) and operation codes (e.g. upper and lower gastrointestinal endoscopy) is included in this report. This is intended to reflect the "fitness for purpose" of the data for statistical analyses in these specific areas. For example, the group of coronary heart disease codes was recorded with 94% accuracy but with 99% completeness.
Not all coders have equal, full access to clinical information regarding the episodes they are coding. For the 17 hospitals where the coders do not have access to the full medical record, we found that 44% of the major errors in Main Diagnosis and 37% of major errors in Main Operation and 60% of major errors in Other Conditions occurred in cases where information allowing correct coding was not available to the coders in the documents to which they had access.
Ethnic group is only being recorded on admission in five of the 38 hospitals we assessed. It may well be that this data item is recorded at a later stage in the patient's hospital stay but we specifically looked for it at the point of admission when the patient details are recorded in the hospital computer system in advance of the SMR01 (national return) being produced on the patient's discharge. As ethnic group is not a mandatory data item for national returns thus it is not frequently recorded.
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MAIN CONTACTS:
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GLOSSARY:
SMR01 is the national administrative return for In-Patient and Day Case activity.
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PRE-RELEASE ACCESS TO THIS PUBLICATION WAS GIVEN TO:
NHS Board Chief Executives
Hospital Chief Operating Officers
Medical Directors
Caldicott Guardians
Hospital Medical Records Managers
Hospital Chief Operating Officers
Medical Directors
Caldicott Guardians
Hospital Medical Records Managers
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HISTORY OF THIS PUBLICATION:
Not applicable though a similar report on SMR01 data quality was published in 2004.
Main contact: 
Margaret Mason
Margaret Mason
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