Data Collection And Data Reporting

Data Collection

Data collection is the continuous process of gathering data according to the measure specifications established for each of the ten harmonized stroke performance measures. Data may be collected for additional non-standardized measures, if a program chooses to monitor other indicators not included in the standardized measure set. All DSC certified stroke programs should be collecting data for all ten standardized measures. Data collection for non-standardized measures may be used to enhance the program’s performance improvement plan, but cannot be used to replace or substitute for data collection for the standardized measures.

Ideally, programs should be collecting data for all ten standardized measures every month; however, other schedules can be utilized (i.e. quarterly) with the provision that monthly data points are gathered and reported (e.g. graphs and/or tables with data plotted for every month of the calendar year.) Programs that do not prospectively collect data due to resource or other constraints should take steps to ensure that the appropriate number of cases is reviewed and findings displayed for each month.

Example:
In October, a program reviews 60 patient records for third quarter stroke performance measure data. The sample selected should include 20 records from stroke patients discharged in July, 20 from patients discharged in August, and 20 from patients discharged in September. All 60 records should not be pulled from stroke patients discharged in October, leaving gaps in monitoring for other months.

Data Reporting

Data reporting is a periodic event that provides the organization with an opportunity to share the findings and analyses of its data collection efforts with internal staff members, other departments, or similar programs in an integrated health system delivery network. Data reporting at intervals determined by The Joint Commission is also a requirement for DSC certification.

Data reported to The Joint Commission should include the numerator and denominator figures for each measure, not just rates. Generally, the numerator is the smaller of the two numbers, and the denominator is the larger. The Performance Measure Data Report (see Appendices) is used to report data to The Joint Commission at the time of intra-cycle review and recertification. Graphic data displays should be used to demonstrate data analysis and included as part of the periodic data report. Data reporting should be done on a calendar year, rather than fiscal year basis.

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