` SOP-C&R-01

Standard Operating Procedure of

Internal process for data collection Analysis

1 PURPOSE

To standardize an internal process of data collection & Analysis

2 SCOPE
Quality measures, Indicators, Outcome Measures

3 RESPONSIBILITY

Head of Quality Assurance ,

Manager Compliance & Risk Management

4 ABBREVIATION
NIL

5 RISK RATING AND REVIEWING FRAMEWORK

Risk rating Reviewing framework

Moderate 2 years time

6 PROCEDURE:
6.1 Data collection & Analysis

a) Clinical data will be selected by the relevant HOD/ In charge to measure outcome / patient care at
their unit.
b) Quality Assurance department will conduct training session for the staff on data collection and
take action for improvements.
c) Data analysis will be conducted by the quality assurance department and present in to HOD
meetings.

6.2 Data Validation

A quality improvement program is only as valid as the data that is collected. Internal validation
process ensures that the data collected is –reliable, replicable & accurate.

Data validation is most important when.

Effective Date: 01/01/2023

` SOP-C&R-01
Standard Operating Procedure of
Internal process for data collection Analysis

 New measure is implanted. This applies to clinical measures, clinical processes &
outcomes
 Data is being published
 A change is made to existing measure such as change in data collection tool or data
abstraction process or abstractor has changed
 Data resulting from an existing measure has changed
 Data source has changed.
 Subject of data collection has changed such as new practice guidelines or new
technologies or treatment methodologies.

The data is used to set priorities and implement improvement measures.

Data validation ensures the quality of data and establishes the confidence of decision makers.

The essential steps of data validation process are.

 Re- collecting the data by a second person not involved in original data collection. Re-
collection of data may be done retrospectively or prospectively
 Using statistically valid sample of records or cases. E.g. 10%. A 100% sample would
only be needed when number of cases or records is very small.
 Comparison of original & re-collected data .
 Calculating the accuracy

Number of data elements found to be same X100

Total number of data elements

A 90 % accuracy level is a good benchmark.

 When data elements are not found to be same, noting the reasons (e.g. Unclear
definitions)
 This may result in corrective actions such as change of definitions or modification in data
collection methodologies.
 After implanting the corrective actions, a new sample needs to be collected to check
whether data has achieved the desired accuracy levels.
 Data may be used for

 Comparisons within the group of hospital

 Published on website

The reliability of the data can be established through the above-mentioned internal process of data
validation or can be judged by an independent third party.

Data reliability and accuracy can be enhanced by.

Effective Date: 01/01/2023

` SOP-C&R-01
Standard Operating Procedure of
Internal process for data collection Analysis

1 Defining the parameter, measures

2 Standardizing the calculation methodology
3 Standardizing data collection tools

PREPARED BY: APPROVED BY:

MANAGER COMPLIANCE & RISK MANAGEMENT DIRECTOR ADMINISTRATION
Revision no 01- Review before: Revision no 02- Review before:
Reviewed By: Reviewed By:
Signature: Signature:
1.1.1
Designation: 1.1.2
Designation:
Date: Date:
Reviewed by Quality Assurance Reviewed by Quality Assurance:

Effective Date: 01/01/2023