2022/23 Audit period and new three-tier NJR Quality Data Provider Scheme
The deadline for submission of data for the 2022/23 audit is 30 September 2023.
From the 2022/23 audit year, a new three-tier, Gold, Silver and Bronze awarding system will be applied to our NJR QDP Scheme to further encourage all hospitals to strive to achieve the most excellent data quality standard, and to enable those who achieve this to receive the greatest recognition for achieving excellence in supporting patient safety standards through their compliance with the mandatory NJR data submission quality audit process.
To achieve a QDP award, hospitals are required to meet the criteria set out in the ‘Criteria table’ on the left hand side of this page.
As usual with our awards, those hospitals who achieve Gold, Silver or Bronze award status will have the award emblem placed on their hospital dashboard page on the NJR’s Surgeon and Hospital Profile website, at https://surgeonprofile.njrcentre.org.uk. The website displays orthopaedic data, which is published on an annual basis (refreshed in January each year), for hospitals where any joint replacement operations are carried out, in all the geographical areas where the NJR is operational. You can also request the emblem logo to place it on your own hospital website.
Our NJR Compliance Officers and our NJR Data Quality Officer can offer support to help you attain the targets we have set for the achievement of the award.
If you would like assistance in relation to any of your audits, please contact your NJR Compliance Officer via the NJR Service Desk to request their support by email at firstname.lastname@example.org, or by phone on 0845 345 9991. You can also contact Maggie Tate, NJR Data Quality Officer, via the NJR Service Desk.
|How is baseline compliance calculated?||Baseline compliance is calculated by looking at the number of relevant cases from your hospital PAS upload (excluding those that you have marked as not being NJR procedures or where the patient hasn’t consented) and seeing how many of these have a corresponding NJR record on the first run of the DQA – i.e., before any missing cases are added to the registry.|
|Does the new three-tier system mean a site needs to have an initial score of at least 95% to meet the criteria? As an example, some of our sites start below this threshold but then work on the data to meet the 95%. Will this mean these sites will no longer get the award if that’s the case?||That’s right. We want to award the units that have good systems and processes in place to identify patients at the time of their operation. Where patients are identified later using the DQA, this means it takes longer for us to identify issues and also means that patients are less likely to be asked for their consent.|
|How will the three-tier system work with sites who upload data in sections throughout the year before submitting the whole audit towards the end of the year? Will this ‘part submissions’ process impact their ability to meet the below criteria? If so, is there a way we can check periodically throughout the year a sites compliance without impacting the audit criteria?||Where a hospital submits PAS data more than once in a year (e.g., quarterly) then the baseline compliance is aggregated across each submission to give a single baseline percentage. The status of each case as present or missing is based on its first appearance in the file.|
|What would be the criteria for achieving each of gold, silver and bronze awards? Will it be 100% on initial upload of activity data before any audit correct is gold, silver if after audit 100% is reached and bronze 95 – 99% achievement after audit?||Bronze award is minimum 95% baseline and 98% when missing cases are entered|
Silver award is minimum 97% baseline and 99% when missing cases are entered
Gold award is 99% baseline and 100% when missing cases are entered.
|Other than the data quality audit scores, what other criteria must be met to achieve each of gold, silver and bronze awards?||The full criteria for the award are:|
– Payment of the NJR subscription by 31 December 2022
– Baseline compliance of 95% / 98% / 99%
– Percentage of cases with no status to be no higher than 2% / 1% / 0%
– End state compliance of 98% / 99% / 100%
|Will we get a chance to remove any records which shouldn’t be in the audit (e.g. NJR consent refused) & reprocess the audit before our initial compliance is calculated?||Yes, cases where NJR consent are refused or confirmed to not be NJR procedures will be removed from the denominator for both baseline and end state compliance calculations.|
|How long will we have from the initial upload to look at the audit, remove any records which need to be excluded & reprocess it?||Any cases identified as exclusions within four weeks of the initial upload will be excluded from the denominator for both baseline and end state compliance.|