A Diamond in the Rough

Background CIBMTR audits take place every four years and the University of Maryland Greenebaum Comprehensive Cancer Center, BMT Department has consistently met required thresholds. However, this changed with the 2018 audit when the overall error rate was 3.3%; above the threshold of 3%. The deficiencies identified during the audit necessitated the implementation of strategies to improve data accuracy. Method The CIBMTR audit results identified three key deficient reporting areas. These included: Method of Disease Assessment (specifically cytogenetics), Disease Status, and Acute and Chronic Graft vs Host Disease (aGVHD) (cGVHD). Strategies were developed to address these specific deficiencies. Results First, regularly scheduled meetings with the BMT physicians to review complex, difficult cases/questions/scenarios were instituted. These meetings may include reviewing method of disease assessment in which the DM may be having difficulty extracting the information from a variety of reports; Disease assessment questions for a variety of oncological diseases are often-complicated; a review from the physician to validate reported data is crucial. Identifying the diagnosis date and maximum grade of aGVHD and cGVHD are especially challenging, and are verified with the provider. Second, in May 2019, EMR templates for key documentation requirements were implemented. These templates include the required necessary information for diagnosis dates and grading of both aGVHD and cGVHD, and disease assessment with respect to hematologic, molecular, and radiologic interpretation and are completed by the physician. Third, the number of Internal Assessment (IA) forms audited by the DMs on a monthly basis has increased to a total of 24 forms per month, a 14% increase. This increase in the number of forms audited increases the number of data points examined for accuracy. In addition, auditing practice has changed in that the same patients are reviewed over time. The BMT program manager reviews the forms at a monthly audit review meeting. If there are errors, the correction(s) is/are made into FormsNet3. If error trends are identified a CAPA is implemented with the guidance of the Quality Manager. The BMT team also increased the acceptable audit results from 97%-100% to 98%-100%. Conclusion These three strategies are key to achieving the desired result of greater than 98% accuracy rate on completed, submitted CIBMTR forms. The communication meetings with the physicians have broken down the barriers between physicians and DMs and brought everyone to work together toward a common goal. The EMR templates provide a tool for the physicians to document the essential data required. Finally, adding additional IA forms to be audited will provide additional checks for data accuracy. As a result of these strategies, achieving a goal of 98%-100% data accuracy for submitted CIBMTR forms is feasible.