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| Journal to Optimal Data Validation |
| Marc Koch, Stephen Songhurst, Linda Caccamo, Alicia Sicoli Somnia, Inc., Harrison, NY, United States |
BACKGROUND: In healthcare, the concept of self-reporting quality and patient safety data is generally met with skepticism because data validation is oftentimes missing. Part of what makes the data validation process so challenging is the fact that data collection tools and processes can differ greatly across the healthcare landscape with some facilities relying on paper records while others utilize one of many electronic health records systems. Meanwhile, many healthcare facilities use this quality data to provide answers to questions related to patient outcomes, treatment efficacy and clinician performance. Our goal is to examine the accuracy of self-reporting at two different hospitals within our network to determine baseline performance. METHODS: In this study, a total of sixty anesthesia charts evenly split among two hospitals with dates of service ranging from October 7, 2023, to December 3, 2023, were reviewed side by side with self-reported outcomes forms for documentation accuracy. Fields such as case urgency, ASA classification, anesthesia method, comorbidities, medical procedure, and adverse events were compared. RESULTS: Of the sixty cases reviewed across the two hospitals, 100% of charts had the same anesthesia method listed on the self-reported outcomes form. Similarly, 93.3% of cases had the same ASA classification and 88.3% had the same case urgency documented. The medical procedure was documented the same way in 90% of cases and adverse event documentation matched in 95% of cases. Documentation of comorbidities only matched in 30% of cases. A case would not be considered a match if one or more comorbidities differed from anesthesia to outcomes form. CONCLUSIONS: This study suggests that quality self-reporting may warrant the need for greater data validation efforts. A larger sample will help us diagnose the severity of improper documentation with greater precision. Evaluating field definitions and providing additional clinician training will be considered when evaluating improvement efforts. |