2018 HRIF-QCI Data Finalization Guidelines and Tools HRIF... · DATA FINALIZATION GUIDELINES HRIF-QCI CLOSEOUT CHECKLIST OVERVIEW The online Closeout Checklist tool is to help guide

HRIF-QCI: DATA FINALIZATION PROCESS GUIDELINES AND TOOLS – RELEASE 02.18 1

HIGH RISK INFANT FOLLOW-UP QUALITY OF CARE INITIATIVE DATA FINALIZATION PROCESS GUIDELINES AND TOOLS 2014 BORN INFANT RECORDS 2016 BORN INFANT REFERRAL/REGISTRATIONS FORMS 2016 BORN INFANT STANDARD VISIT #1 FOR ALL EXPECTED 2017 BORN INFANT REFERRAL/REGISTRATIONS 2018 CALIFORNIA CHILDREN’S SERVICES (CCS) & CALIFORNIA PERINATAL QUALITY CARE COLLABORATIVE (CPQCC), HIGH RISK INFANT FOLLOW-UP QUALITY OF CARE INITIATIVE (HRIF-QCI). THIS PUBLICATION IS COPYRIGHTED AND IS NOT TO BE REPRODUCED IN WHOLE OR IN PART WITHOUT WRITTEN PERMISSION FROM CCS/CPQCC HRIF-QCI.


TABLE OF CONTENTS INTRODUCTION PAGE 3 Deadline Deliverables HRIF-QCI Support Contacts Communication Resources

DATA FINALIZATION GUIDELINES PAGE 5 HRIF-QCI Closeout Checklist Overview Procedures for Finalizing Data REPORTING SYSTEM TOOLS OVERVIEW PAGE 8 HRIF Record Tracker CPQCC Reference Number Error and Warning HRIF/CPQCC Match Status Report


INTRODUCTION CCS/CPQCC HRIF-QCI is responsible for all data finalization procedures for the CCS HRIF Programs. The purpose of this data finalization process is to assist HRIF Programs with meeting the HRIF-QCI Program goals for complete, accurate and timely data submissions. DEADLINE DELIVERABLES The following deadlines list deliverables that are required to be completed for data submission of records for infants born in 2014, Referral/Registration (RR) Form closed for All 2016 born infants, Standard Visit (SV) #1 [and/or Additional Visit(AV)] for All expected 2016 born infants AND RR Forms for infants born in 2017. January Submit a Help Ticket (www.cpqcchelp.org)to schedule a data review (optional)

April 1st Qualify for the Super Star HRIF Program Award for completing the May 1st

deliverables May 1st • Submission of no priority cases for the birth year 2014

• Submission of no error or warning cases for the birth year 2014 • RR Forms closed for All 2016 born infants • Submission of SV #1 (and/or AV) of All expected 2016 born infants

May 2nd Qualify for the HRIF Follow-up Rate Award for meeting the core visit follow-up rate for infants born in 2014

May 17th Confirmation of the HRIF CCS report for the birth year 2014 NOTE: The report will be available on May 2nd.

July 1st • Registered and accepted all eligible HRIF infants from your CPQCC CCS NICU center for birth year 2017

• Review and sign-off on the CPQCC & HRIF-QCI Directory HRIF-QCI SUPPORT CONTACTS For questions or any assistance, it is recommended to submit a ticket to the CPQCC Help Desk (www.cpqcchelp.org) . The Help Desk will be the primary source for all request related to HRIF-QCI. NOTE: When creating a ticket select “HRIF Support” as the Help Topic, this will insure that the ticket will be sent to HRIF Support.

Technical Support: CPQCC/HRIF provides technical support for the web-based Reporting System. Please direct all of your questions and comments regarding the HRIF-QCI Reporting System to our HRIF Support staff:

CPQCC Help Desk www.cpqcchelp.org Erika Gray [email protected]

Policy and Procedure Support: For CCS HRIF Program policy and procedure issues contact Children's Medical Services (CMS) Branch Staff:

CCS HRIF Program [email protected] Maria Jocson, MD [email protected]


COMMUNICATION

o MailChimp – HRIF-QCI Program communication (i.e. Monthly Newsletter Bulletins, System Improvements, and other announcements) will be sent via the MailChimp email client. Make sure to update e-mails or contact changes in the CPQCC & HRIF-QCI Directory. If you are unable to receive MailChimp e-mails, please submit a Help Ticket.

o To subscribe to our program e-newsletters and/or update your MailChimp profile, please complete the online form at: www.eepurl.com/4cOsD

o CPQCC Help Desk – Please submit a help ticket for all data and program related requests,

inquiries, feedback etc. The help desk will also be the primary resource for data finalization request. Visit the CPQCC Help Desk “Frequently Asked Questions” page if you need additional instructions about how to use the CPQCC Help Desk Ticket System: www.cpqcchelp.org

When creating a ticket enter all relevant information:

o Request Type (required): “HRIF Support” o Subject (required): ex: “Transfer Record/Duplicate Records” or “User

Access/Password Reset”. o Description: Describe the reason(s) for opening this ticket in a short summary. o Ticket response within 1-3 days. NOTE: Help Tickets will be closed if left idle for 2 or

more days, after response by HRIF Support staff.

NOTE: CPQCC/HRIF office hours are Monday – Friday 8:00 am – 5:00 pm. All requests sent after hours or on weekends will NOT be responded to until the following business day. RESOURCES

1. HRIF-QCI Website “Resource Corner”: The HRIF-QCI Manual, Reporting Forms, and Data Finalization documentation is listed on the website: https://www.cpqcc.org/perinatal-programs/ccscpqcc-hrif-qci/resource-corner

2. CPQCC & HRIF-QCI Directory: Provides a list of CPQCC and HRIF Program data contacts by hospital. Available on the HRIF-QCI Reporting System under the “Admin” tab => “Update Directory”.

3. Family Information Form: Was developed to help HRIF Programs collect social-demographic

information about HRIF patients and their families to determine the specific needs of this patient population and develop better standards of care for California HRIF Programs. The form is available on the website: https://www.cpqcc.org/perinatal-programs/ccscpqcc-hrif-qci/resource-corner, under Reporting System Tools.


DATA FINALIZATION GUIDELINES

HRIF-QCI CLOSEOUT CHECKLIST OVERVIEW The online Closeout Checklist tool is to help guide HRIF programs through the Data Finalization Process (DFP). The tool is in the HRIF-QCI Reporting System under the “Admin” tab. The Closeout Checklist consist of the following 6 columns:

1. #: the task item number. 2. Item: the description of the deliverable. 3. Resource: active links to tools and resources to aid in completing the deliverable. 4. Deadline: the due date of the deliverable. 5. Complete: checkbox and date stamp to indicate the deliverable is complete.

a. Items #1 thru #5 are grayed out and automatically checked by the system once verified that the deliverable was complete.

b. Item #5 must be checked manually by the HRIF Program AFTER the deliverable is complete.

c. Item #6 is manually checked by HRIF Support staff once complete. d. NOTE: Dates indicated in red were completed after the deadline.

6. Comment Box: User and/or Admin (HRIF Support) can make comments.


AWARDS All earned awards for your HRIF Program will be displayed on the Closeout Checklist. The CPQCC website (www.cpqcc.org) has a page dedicated to each HRIF Program, the “Data Management Awards” page: www.cpqcc.org/about-us/data-management-awards. Programs can view all awards earned from 2014, and can sort the awards alphabetically or by number of awards earned. NOTE: Awards will be announced via CPQCC/HRIF Newsletter Bulletins (MailChimp).

Super Star = Granted to HRIF Programs that completed items #1 through #4 on the Closeout Checklist by April 1st

Follow-up Rate = Granted to HRIF Programs who meet the follow-up rates for the closing

birth year: 1St Visit => 80% 2nd Visit => 70% 3rd Visit => 60%

Crown = Granted to HRIF Programs who meet ALL closeout deliverables: May 1st, May 17th and July 1st

Surprise = Granted to HRIF Programs that a recognized for a random positive performance data quality aspect.


PROCEDURES FOR FINALIZING DATA

NOTE: All Reporting System tools are located in the HRIF-QCI Reporting System under the “Tools” tab, and are updated in real-time.

1. January thru March – Submit/edit data for completeness and accuracy by utilizing reporting system tools

2. April 1st – HRIF Super Star Award Granted

3. May 1st Deadline (11:59 pm): a. 2014 born infant data records are complete and finalized

i. Make corrections and close online entry: Referral/Registration (RR), Standard Visit (SV), Additional Visit (AV) and Client Not Seen/Discharge (CNSD) Forms for all closing year submitted case records.

ii. Review the CPQCC Reference Number report to verify that all eligible CPQCC born infants have a valid CPQCC Patient I.D. Number entered.

iii. Review the HRIF Record Tracker tool to verify that all closing year case records are closed. Focus on Priority and Warning Cases .

iv. Review the Error and Warning Report tool to verify that all closing year case records are complete.

b. Submission of SV #1 (and/or AV) for all expected 2016 born infants i. Review the HRIF Record Tracker tool to verify that all expected 2016 born

infant records have a SV #1 or AV form submitted and closed. c. Close Referral/Registration (RR) Forms for All 2016 born infants

i. Review ALL 2016 born infant records RR Form to verify that the “This Form is Closed” checkbox is checked.

4. May 2nd – HRIF Follow-up Award Granted

5. May 2nd until May 17th (11:59 pm) - Review and Confirm the final 2014 HRIF CCS Report:

a. The HRIF CCS Report will be available on April 2nd (located under the “Report” tab) b. The HRIF Medical Director or Coordinator must confirm the report by May 17th. c. If the HRIF Medical Director of Coordinator is unable to confirm, then a proxy can

confirm the report.

6. July 1st – Deadline (11:59 pm): a. Register all 2017 born infants. The Reporting System will NOT accept referrals of

infants born prior to 2017 i. Collaborate with the CPQCC Data Contacts or NICU Discharge Planner to

verify that all HRIF eligible infants have been referred/ registered. ii. Review the “HRIF/CPQCC Match Status Report” available at www.cpqccreport.org.

Submit a Help Ticket if you need access to the CPQCC Report website. iii. Review the CPQCC Reference Number report to verify that all eligible

CPQCC 2017 born infants have a valid CPQCC Patient I.D. Number entered. b. Review and sign-off on the HRIF-QCI Directory

i. The directory survey is located under the “Admin” tab. ii. It’s required to enter a full name before submitting the survey.

7. July 11th – HRIF Crown Award Granted

8. August thru December – Submit/edit data for completeness and accuracy by utilizing

reporting system tools.


REPORTING SYSTEM TOOLS OVERVIEW

HRIF RECORD TRACKER The purpose of the HRIF Record Tracker tool is to help HRIF Programs track and finalize/close patient records. The system will display the “Date Expected” for when the patient should have been seen for SV #1, #2 and #3, based on the recommended time frames. The “Date Expected” is calculated by using the patient’s gestational age. Once the SV is submitted the “Visit Date” and the visit “Disposition” will override the “Date Expected”. NOTE: The HRIF Record Tracker is located in the HRIF-QCI Reporting System under the “Tools” tab and is updated in real-time. Case Status Definitions:

Priority Cases are patient records with current adjusted age => 37 months and has one of the following:

1. Only has a RR Form in the system (No SV forms submitted) 2. Open Forms = the “This Form is Closed” check box has not been checked 3. “Non discharged” disposition selected to close the case 4. Priority Cases are highlighted in RED

Warning Cases are patient records with current adjusted age < 37 months with a “non discharged” disposition selected to close the case and has one of the following:

1. Open Forms – the “This Form is Closed” check box has not been checked 2. Missing SV Form(s) 3. Warning Cases are highlighted YELLOW

Closed Cases are patient records with the following:

1. All forms are Closed – the “This Form is Closed” check box has been checked 2. A “discharged” disposition has been selected to close the case

Guidelines (Priority Cases): 1) If the record is missing any Standard Visit (SV), Client Not Seen/Discharge (CNSD) or Additional

Visit (AV) Forms. The HRIF Program must enter the form(s) and then close the case. 2) If the patient was never seen, OR the latest SV or CNSD Form entered has a “non-discharged”

disposition (ex: “Schedule to Return”) and the client NEVER returned for further visits. The HRIF Program must submit a Client Not Seen/Discharge Form and select a “discharged” disposition to close the case.

3) If the patient received 3 SVs, and the 3rd visit disposition = “Will be followed by Another CCS HRIF

Program”, this indicates the case as “open” due to the “non-discharged” disposition entered. The HRIF Program can either change the 3rd visit disposition to “Discharged - Completed HRIF Core Visits, Referred for Additional Resources” OR if the client returned for a further visit, then submit an AV Form and select a “discharged” disposition to close the case.

4) If the latest SV or CNSD Form entered has a disposition = “Will be followed by Another CCS HRIF

Program”, BUT the record was NEVER properly transferred, then there may be a duplicate record in the system. Submit a Help Ticket at www.cpqcchelp.org to resolve the issue. NOTE: If no duplicates are found, then the HRIF Program must submit a CNSD Form and select a “discharged” disposition to close the case.


5) If the patient has completed all 3 core visits AND has a “discharged” disposition, then the record

must have open forms. The HRIF Program must check the “Case History” to make sure all form status = Closed”.

MANAGE CPQCC REFERENCE NUMBER The purpose of the CPQCC Reference Number tool is to provide a full list of all your HRIF programs registered infants and allow program staff to update the CPQCC Reference Numbers. The tool can be filter by Infant’s Birth Year/Month and/or Birth Weight: All, Small Baby (=< 1500 grams) and Big Baby (=>1500 grams). NOTE: All Small Babies born or discharged from a CPQCC CCS NICU should be assigned a CPQCC ID Number. Data Item Definition - CPQCC Reference Number Enter the last six-digits of the discharging/referring or birth CCS NICU hospital’s Office of Statewide Health Planning and Development (OSHPD) facility code (Appendix E) and the infant/child’s CPQCC Network Patient Identification Number from the discharging/referring or birth CCS NICU hospital, where the infant/child was born or admitted within 28 days of birth. The CCS NICU discharging the infant/child home could also be the same facility referring the infant/child to the HRIF Program. The OHSPD facility code and CPQCC Network Patient ID Number must match. If you use the birth hospital’s OSHPD code then you must use the birth hospital’s CPQCC Network Patient ID Number. NOTE: Enter “99999” as the CPQCC Network Patient ID Number or check the “Infant NOT CPQCC Eligible” check box, for infants who did not qualify for CPQCC NICU eligibility criteria. Every CPQCC / CCS NICU hospital has a CPQCC data contact person that keeps a record of each patient who meets the CPQCC NICU eligibility criteria. The “CPQCC & HRIF-QCI Directory” is available in the Reporting System located under the “Admin” tab => “Update Directory” => “Download Directory”, use this directory to identify the CPQCC data contact person(s) from the discharging/ referring or birth CCS-approved NICU hospital.

NOTE: Enter “00000” as the CPQCC Network Patient ID Number, if you are not sure if the infant met the CPQCC NICU eligibility criteria or the CPQCC data contact person is backlogged and, therefore has not assigned a CPQCC Network Patient ID Number for the infant. Use the “CPQCC Reference Number Report” to replace assigned CPQCC Network Patient ID Number(s). NOTE: Enter “77777” as the CPQCC Network Patient ID Number, if the infant met CPQCC NICU eligibility criteria, but was not assigned a CPQCC Network Patient ID Number.


ERROR AND WARNING The purpose of the Error and Warning tool is to alert HRIF Programs of missing or incorrect data entries and to help aid them in completing and finalizing their data. The system will display patient records with any of the following issues: “Duplicate Record”, “Missing CPQCC ID Number”, “No Forms”, “Transfer Record Incomplete”, “Met Age Limit for Program”, “Missing Birth Date of Mother”, “Incorrect Date of Visit”, “Duplicate Core Visit”, “Missing Discharge Date”, “Expected SV #1 Missing” , and “Open RR Forms” with an action plan to resolve the issue. NOTE: The Errors and Warning tool is located in the HRIF-QCI Reporting System under the “Tools” tab and is updated in real-time. Issue Definitions:

1. Duplicate Record = displays matched records across the entire HRIF-QCI database.

2. Missing CPQCC ID Number = displays patients with birth weights =< 1500 grams, and the CPQCC Reference Number CPQCC Network Patient ID Number is coded as “00000”, “99999”, or “0000”.

3. No Forms = displays records for patients who are currently => 12 months adjusted age and

DO NOT have a (SV, AV or CNSD) form submitted in the database.

4. Transfer Record Incomplete = displays records that have a “Will be Followed by Another CCS HRIF Program” disposition entered on the SV, AV or CNSD Forms.

5. Met Age Limit for Program = displays records for patients who are currently => 3 years old

and the record has not been closed with a “discharged” disposition.

6. Missing Birth Date of Mother = “Mother” or “Both Parents” selected as Primary Caregiver, then “Birth Mother’s DOB” can NOT be entered as “Unknown”.

7. Incorrect Date of Visit = enrollment date cannot be the same as the infant’s date of birth.

8. Duplicate Core Visit = record has multiple core visits with the same date of visit.

9. Missing Discharge Date = displays records with “Still in Hospital” checked on the RR Form.

10. Expected SV #1 Missing = displays records for patients who are => 8 months adjusted age

and do NOT have a (SV#1 or AV) form submitted in the database.

11. Open RR Forms = displays open RR Forms.

Guidelines: 1) How to Resolve Duplicate Records:

a. Contact the HRIF Program with the duplicate case to review the records. b. Make sure all data variables are captured on the RR Form (CPQCC Reference Number,

Birth Mother’s Date of Birth, Discharge Date to Home, etc). c. *Combine all data forms (SV, AV and CNSD Forms) into the current or record of choice. d. The HRIF Program not currently following the patient should remove the record from the

system. Located at the bottom of the RR Form entry screen check the “Delete Patient


Record” checkbox, cite the reason, and then click the orange "Delete" button to remove the record from the system. *TIP: Use the "Patient Data Quality Self-Audit Instrument Report" located in the "Patient's Case History" page to review the details of the record.

2) Missing CPQCC Network Patient ID Number:

a. Contact the CPQCC Data Contact person from the birth OR discharging CCS NICU to obtain the CPQCC Network Patient ID Number. Use the CPQCC & HRIF-QCI Directory to get contact information.

b. Review the “HRIF/CPQCC Match Status Report” available at www.cpqccreport.org. Submit a Help Ticket if you need access to the CPQCC Report website. NOTE: The OHSPD facility code and CPQCC Network Patient ID Number must match. If you use the birth hospital’s OSHPD code then you must use the birth hospital’s CPQCC Network Patient ID Number.

3) No Forms:

a. Submit the missing SV or AV form(s) b. If the child was never seen submit a CNSD form and indicate the reason and disposition

as to why the patient was not seen

4) Transfer Record Process: a. Contact the CCS HRIF Program Coordinator where the patient will be transferred for

follow-up care, to inform them of the patient and the HRIF ID #. b. Submit a “CNSD Form”, before requesting to transfer the patient’s record:

Category: "No Scheduled Appointment” Reason: "Infant Referred to Another HRIF Program" Disposition: "Will be Followed by Another CCS HRIF Program"

c. Submit a Help Ticket at www.cpqcchelp.org to request the record transfer to another

CCS HRIF Program. Include in the transfer request the patient’s “HRIF ID Number”, “Date of Birth” and the “CCS HRIF Program, where the patient will be transferred”. NOTE: Records are transferred every Friday; request received on Friday will be transferred the following week.

Records are only transferred to CCS HRIF Programs. If the infant is referred to a NON-CCS or Out of State HRIF Program, submit a “CNSD Form” to close the case:

Category: “Discharged” Reason: “Infant Referred to Another HRIF Program” Disposition: “Discharged – Will be Followed Elsewhere”

5) Met Age Limit for HRIF Program:

a. Submit a “CNSD”, to close the patient’s record: Category: “Discharged” Reason: Select a reason or code as “Other = Aged out of Program” Disposition: “Discharged – Closed Out of Program”

6) Duplicate Core Visit: a. Update and enter the correct date of visit OR delete the duplicate core visit


7) Missing Discharge Date: a. Uncheck the “Infant Still in Hospital” check box b. Enter the date when the child was discharged to home NOTE: The Date of Discharge to Home is a required field and must be completed.

8) Expected SV #1 Missing:

a. Submit the missing SV #1 or AV form b. If the child was never seen submit a CNSD form and indicate the reason and disposition

as to why the patient was not seen

9) Open RR Forms: a. Click “This Form is Closed” or “Unable to Complete” checkbox to close the form.


HRIF/CPQCC MATCH STATUS REPORT The purpose of this report is to show the HRIF registration status for each infant coded as discharged to home or discharged to home from the reporting center after one prior transfer out and re-admission. The report lists the basic information included in an infant's HRIF registration and can be filtered based on several criteria. CPQCC offers two reports that are designed to assist NICUs in the identification of HRIF eligible infants and their HRIF registration status. These reports are based on a daily update of a linkage of CPQCC infants and HRIF registered infants, the following automated tasks are performed that facilitate these reports:

1. Multiple encounters within CPQCC of the same infant are reconciled, and the encounter that resulted in a discharge home is made available for linkage to HRIF.

2. The set of CPQCC infants discharged home is linked to a list of new and updated HRIF registrations daily. This linkage is based on the following information: CPQCC ID number (if provided during the HRIF registration), infant date of birth, infant gender, mother's date of birth, hospital of birth, hospital infant was discharged home from, gestational age at birth, birth weight and multiple status (including birth order).

The daily linkage is based on a probabilistic match technique that generates a match score for each HRIF registration and CPQCC infant. Matches with a high score are presumed to be matches, however, this technique hinges on accurate reporting of the match variables. Therefore, if an HRIF registration and CPQCC record persistently do not match, both, the HRIF registration information and CPQCC record should be reviewed closely for any discrepancies. If a record continues to not match, please submit a https://www.cpqccsupport.org/. The following two reports are available on https://cpqccreport.org:

• HRIF/CPQCC Match Summary Report provides match results for several key group of HRIF eligible CPQCC infants. For each group, the number of infants discharged home from the reporting NICU, that meets the group criterion is shown along with the percent of these infants registered with HRIF. A summary report including all years since 2009 and yearly summary reports are available.

• HRIF/CPQCC Match Status Report provides detailed HRIF registration status information for all CPQCC infants. This list can be filtered to efficiently find infants that meet HRIF criteria, but are not registered.

The following notes pertain to the HRIF/CPQCC Match Status Report. The CPQCC/HRIF linkage focuses on the following groups of infants that are eligible for both, CPQCC and HRIF:

1. Extremely Low Birth Weight Infants (ELBW) or infants with a birth weight of ≤ 1,000 grams who are admitted to the reporting NICU at age 28 days or earlier.

2. Very Low Birth Weight Infants (VLBW) or infants with a birth weight of ≤ 1,500 grams who are admitted to the reporting NICU at age 28 days or earlier.

3. Infants born at less than 28 weeks completed gestation who are admitted to the reporting NICU at age 28 days or earlier.


4. Infants born at 29 to less than 32 weeks completed gestation who are admitted to the reporting NICU at age 28 days or earlier.

5. Infants born at 36 weeks completed gestation or later and who received a diagnosis of moderate or severe HIE during their NICU stay who were admitted to the reporting NICU at age 28 days or earlier.

6. Infants who experienced active cooling during their NICU stay and who were admitted to the reporting NICU at age 28 days or earlier.

7. Infants with ECMO during their NICU stay and who were admitted to the reporting NICU at age 28 days or earlier.

An infant might meet other HRIF eligibility criteria, but not be eligible for CPQCC; and vice versa, an infant might meet other CPQCC eligibility criteria, but not be eligible for HRIF. Unlinked CPQCC records listed with an HRIF eligibility criterion different from "-" pertain to infants who meet one of the criteria listed above. In other words, based on the CPQCC record, one of these criteria can be validated for these records, and these CPQCC infants should always match to an HRIF registration. All Unlinked CPQCC records listed with an HRIF eligibility criterion of "-" might include CPQCC eligible infants who are not HRIF eligible. Unlinked HRIF records pertain to all unlinked HRIF infant registrations that do not match to a CPQCC record. However, except for the group of VLBW infants and infants born at < 32 weeks completed gestation, we do not know whether the infant qualified for CPQCC. Therefore, the HRIF/CPQCC match status report might include unlinked HRIF records that will never link to a CPQCC record. To help you focus on those HRIF records that should link, we have highlighted records pertaining to VLBW infants or infants born at < 32 weeks completed gestation in red as in Unlinked HRIF record. The HRIF/CPQCC Match Status Report might be helpful for:

1. Identifying unlinked CPQCC infants that should be registered with HRIF Set the filter to Unlinked CPQCC record, HRIF Eligible due to VLBW, GA, HIE, ECMO or Cooling. Only those CPQCC records must be linked to an HRIF record to meet the CPQCC close-out requirement of 100% HRIF registration of eligible infants.

2. Identifying unlinked HRIF records Set the filter to Unlinked HRIF record. Only those HRIF records are shown that are not matched to a CPQCC record. NOTE: That not all these records have to be matched to a CPQCC record. In fact, some of these infants might not be part of the CPQCC data collection (admitted after 28 days; HRIF eligible, but not CPQCC eligible).

3. Understanding why an HRIF record does not match Matching HRIF registrations and CPQCC records hinges upon finding a minimum level of agreement between the data in the two records. Most important for matching is the birth date, location of birth, infant sex, and multiple status. For multiples, birth order, number of multiples in set and birth weight are extremely important for identifying matches. Maternal birth date, discharge date and gestational age provide important additional information especially if there is disagreement on the primary match variables. Finally, knowing the CPQCC ID number, increases the likelihood of matching a CPQCC and HRIF record substantially.


We recommend using the ability to sort the report table based on any of the columns to explore non-matching issues:

o The default sort order for the list is determined by date of birth. The sort order can be changed to be based on any of the columns by clicking on the column header. For instance, if birth date is mis-coded in either HRIF or CPQCC, sorting by birth weight (clicking on the column header of the birth weight column) might allow locating a matching infant.

o For all other infants, set the filter to Unlinked CPQCC record or unlinked HRIF registration, HRIF eligible based on CPQCC. This filtered list includes all unlinked HRIF registrations and the subset of CPQCC records that pertain to an infant that qualifies for HRIF, but is not currently matched. Use the sort functionality built into the table to identify missed matches.

o Use the filter setting Unlinked CPQCC record or unlinked HRIF registration to see all unlinked CPQCC records (many of which pertain to infants not eligible for HRIF) and all unlinked HRIF registrations.

o It is possible that the CPQCC data is incomplete, and that a CPQCC record for an HRIF eligible infant has not yet been submitted. In this case, the HRIF record cannot link until the CPQCC record has been entered.

If for an unlinked HRIF record a matching unlinked CPQCC record is found from the list review, ensure that the key variables are coded correctly in both records: birth date, gender, birth location, multiple status and birth weight. For infants who are in a set of multiples, ensure that birth order, the number of multiples in the set of multiples and birth weight are all accurately coded. Note again that adding the CPQCC ID number associated with the infant's NICU stay aids the linkage process. This step might require corrections in the CPQCC record, HRIF record or both. For VLBW infants or infants qualifying for HRIF due to gestational age, set the filter to Unlinked CPQCC record or unlinked HRIF registration, HRIF eligible due to VLBW or GA.

4. Finding duplicate HRIF registrations Once a CPQCC infant and an HRIF registration have been matched, the CPQCC record is no longer included in the pool of potential matches for HRIF registrations. Therefore, if you find that a registration that positively belongs to a CPQCC eligible infant is not matching, it is possible that the infant you are trying to match to is already matched to another HRIF registration. It is possible to identify these situations by setting the filter to All infants discharged home from .... Find the HRIF registration that does not match and look at the surrounding matched records to see whether the CPQCC infant that you are intending to match to is already matched. Use the ability to sort the table by other match variables. Any duplicate HRIF registrations should be deleted.

5. Understanding why an HRIF registration does not show up at all HRIF registrations are shown if they have been either linked to a CPQCC record, or if they have not been linked to a CPQCC record, but the HRIF information in the record indicates that the infant should have been registered by the reporting NICU, i.e., the infant was discharged home from the reporting NICU. The HRIF match pool is updated daily at midnight with all infants that have been registered with HRIF through the prior day. Note that we attempt to update the HRIF/CPQCC linkage daily, but as a daily brief manual review of borderline matches requires daily attention by a staff member, you should always check the information on HRIF registrations included in the HRIF/CPQCC most recent linkage at the top of the report. Therefore, if an HRIF registration does not show up in the list


o Check whether the infant was discharged home from the reporting NICU and is coded as such in the HRIF record.

o Check whether the HRIF registration was submitted prior to the most recent HRIF/CPQCC linkage update shown at the top of the report.

The HRIF reports are not available for sub-center reporting (i.e., reporting restricted to outborn infants transported into a NICU from a specific referral location). NOTE: The HRIF match pool is updated daily at midnight with all infants who were registered in HRIF the prior day. Always check the information on HRIF registrations and compare to must current HRIF/CPQCC Match Status Report. If a HRIF registration does not show up on the report:

• Check whether the infant was discharged home from the reporting NICU and is coded as such in the HRIF record.

• Check whether the HRIF registration was submitted prior to the most recent HRIF/CPQCC linkage update (date shown at the top of the report).

Documents

2018 HRIF-QCI Data Finalization Guidelines and Tools HRIF... · DATA FINALIZATION GUIDELINES HRIF-QCI CLOSEOUT CHECKLIST OVERVIEW The online Closeout Checklist tool is to help guide