Monthly Internal Assessments Result in Successful CIBMTR Audit

Monthly Internal Assessments Result in Successful CIBMTR Audit

BACKGROUND:   The University of Maryland Blood and Marrow Transplant (BMT) team has a reputation of establishing a culture of continuous quality improvement to assure the utmost accuracy of CIBMTR data.  In early 2012, Minas and Ruehle reported the significance of auditing 10 commonly used data points.  In early 2013, Minas and Ruehle set out to further improve CIBMTR data accuracy by combining their original set of commonly used data points with 19 additional ones.  In early 2014, Minas and Ruehle developed a survey to explore the internal assessment audit activities utilized by 137 CIBMTR affiliated transplant centers.  METHODS:  To manage any current or possible data quality issues at transplant centers CIBMTR performs an audit every four years.  CIBMTR randomly selected 16 University of Maryland BMT transplants for audit in 2014.  To be eligible for audit, one of the following form combinations must be submitted to the outcomes registry:  Pre-Transplant Essential Data (TED), 100 Day Post-TED Forms (Form 2400 and Form 2450), and CIBMTR Case Report Forms (Form 2000 and Form 2100).  To pass a CIBMTR audit the critical field rate must be less than or equal to 3%.  RESULTS:  University of Maryland BMT team passed with a critical data field rate of 1.6%. The random data field error rate was 2%, and the overall data field error rate was 1.7%. Out of 7,632 overall fields audited there was an error total of 132 (1.7%).  Of the 5,956 critical data fields audited the error total was 98 (1.6%).  The remaining 1,676 random data fields audited had an error total of 34 (2%).  Of the 1.6% critical data fields, the identified field errors were categorized as follows:  GVHD (30.6%), disease status (24.5%), latest disease assessment (22.4%) and miscellaneous critical field errors (22.5%).  The consent forms were 100% accurate.  There was no corrective action required.  Some of the random data field error trends included the reporting of co-morbid conditions and post-HCT therapy.  CONCLUSION:  Internal assessments have been well worth the time and effort of the data managers for external audits.   Why?  Our FACT (Foundation for the Accreditation of Cellular Therapy) audit was 100% accurate, which we attribute to the continuous quality improvement of CIBMTR data.  Moreover, in February 2014, the CIBMTR audit resulted in an excellent critical error rate which is important in maintaining the highest levels of excellence.