NJR Data Quality Committee (DQC)
Chair’s report 2025 – Mr Derek Pegg
Chair, NJR Data Quality Committee
We have continued to focus on completing our annual data quality audit for the current audit year, alongside supporting hospitals to complete audits for any outstanding yearsThe benefits of the automated data quality audit process, introduced in 2019, is that hospitalscan review their data more regularly and complete audits in a timelier manner.
There remain a few hospitals where compliance is poor and their engagement with the annual audit cycle has been consistently deficient. There are often multiple issues within such hospitals. The NJR will continue to support them as much as possible, to achieve the data quality many of their peers consistently manage. We have reviewed our escalation process that is in place for poorly compliant hospitals, to help clinicians access appropriate support. Ten hospitals are currently in this escalation process due to their poor engagement with the data quality cycle.
During 2024/25, qualifying hospitals were again awarded data quality provider awards in line with the new three-tiered criteria issued last year. From a total of 418 hospitals, 314 (75%) qualified for an award with 251 hospital teams receiving gold (60%), 49 receiving silver (12%) and 14 (3%) receiving bronze. It was encouraging that this year, there was an increase in the number of hospitals qualifying for an award and within the highest category. Work is continuing to support those hospitals who did not qualify to ensure they meet the criteria for the current audit year.
The latest audit year review records the most complete data capture in the last 22 years. The overall compliance is now 97.73% for primary and revision procedures.
59% hospitals have achieved 100% compliance and 72% over 98%. However, a couple of hospitals have struggled to reach even 30% compliance.
To ensure that the NJR can audit procedures added to the registry as part of the updates to the data collection forms, including the new form for Reoperations other than revision (RO), additional codes have now been included within the annual data quality audit. These codes will enable the NJR to audit hip hemiarthroplasty procedures, DAIRs and DAIRs without modular exchange. Further work is ongoing to establish appropriate mechanisms to audit Manipulation Under Anaesthesia (MUA) procedures and fixations of periprosthetic fractures.
In August 2023, the NJR commenced an audit to retrospectively check and improve the volume and quality of registry shoulder replacement data. The audit completed on 31December 2024 with approximately 5000 new shoulder procedures added to the registry. Following completion of the audit, the NJR is now in a position to commence planning for mortality and revision outlier analysis. We would like to thank Mr Jaime Candal-Couto, who is leading this work for the NJR, in collaboration with BESS and BOTA.
Future Plans
During 2025/26 the following data quality activity is planned
- Benchmarking of the NJR vs. HES data to identify hospitals who are not currently entering any hip hemiarthroplasty procedures onto the registry.
- A comparative audit of NJR vs, HES for ankle procedures.
- Continuation of work to identify mechanisms to audit periprosthetic fractures and MUA procedures collected as part of the RO form introduced as part of MDSv8.