A Culture of Continuous Quality Improvement Improves Registry Data

Background:  To ensure the highest degree of accuracy of CIBMTR (Center for International Blood and Marrow Transplant Research) data, the University of Maryland Blood and Marrow Transplant team established a culture of continuous quality improvement. In early 2012, Minas and Ruehle reported the significance of auditing 10 commonly used data collection points.  Since that time, their program set out to identify additional data points of significance. Methods:  The Blood and Marrow Transplant Program Manager and Data Managers continued to evaluate the quality of their data by selecting 19 additional data points for audit to assess the significance of adding these additional data points to the 10 commonly used ones. The CIBMTR forms of four subjects per month (40%) were randomly selected for audit from August 2011 to August 2012, for a total of 48 charts. Results:  Our results demonstrated that adding the extra data points covers 90% of the data reported while the commonly used data points cover only 50 % of the data reported; thereby demonstrating a more comprehensive review of the information reported. Implementing the regular internal audit using the 10 commonly used data points demonstrated better percentage (range 89% to 100%) of data accuracy from that previously reported before implementing the regular internal audit. When the 19 additional data points were reviewed as a whole, there was a 96% accuracy rate.  Corrective action was taken by reviewing all CIBMTR forms with less than 100% accuracy rate and correcting the data in the electronic database.  Education is given on the individual level and for the group as trends become prevalent.  Conclusion:  Implementing internal audits on a regular basis using the commonly used data points and the additional 19 data points have improved the accuracy of the data from what has been previously reported. By maintaining a regularly scheduled comprehensive review, we are able to track trends on an individual and group basis.  Therefore, developing new methods to improve our data prepares us better for challenges of external audits, such as CIBMTR and FACT (Foundation for the Accreditation of Cellular Therapy).

N.M. Minas, K. Ruehle.  CIBMTR Monthly Internal Assessment Improves Quality of     Registry Data.  Biology of Blood and Marrow Transplantation.  Volume 18, Issue 2, Supplement, Page S239, February 2012 [abstract].