DDHA 8703 Week 10 Data Governance Memo Example

Memorandum

To: Analytics Committee, Northgate Health

From: Director of Enterprise Analytics

Date: October 12, 2026

Re: Ownership and change control for reported measure definitions

Decision Requested

The committee is asked to adopt the roles and procedures below for every measure that appears in a recurring Northgate report, effective January 1. The need is concrete. Last year the definition of the outpatient no-show rate changed without notice, and clinic managers spent weeks investigating a rise that came entirely from the change. In July, two emergency departments changed what their arrival time field records, and no report flagged it. Both changes were reasonable. Neither had an owner, a procedure or a notice.

Roles

Each reported measure will have three assigned roles.

The definition owner is the operational leader accountable for the measure, for example the ambulatory operations director for the no-show rate and the emergency services director for emergency length of stay. The owner decides what the measure is meant to show and approves the written definition.

The data steward is a named analyst in enterprise analytics who maintains the definition document, the code that computes the measure and the record of every change. The steward makes sure that the published definition and the running code always match.

The analytics committee approves any change above the threshold below and hears disputes that cannot be settled between owner and steward.

Holmes et al. (2014), reviewing governance of shared clinical data warehouses, found that clear roles and documented procedures were central to governance that worked, and this memo applies that finding to individual measures.

What Counts as a Change Requiring Approval

Changes are divided by size. Technical corrections that do not alter the numerator or denominator population, such as fixing code to match an already approved definition, may be approved by the steward and the owner together and recorded in the change log. Any other change requires committee approval: altering who or what is counted in the numerator or denominator, changing the source of a field, or any change that would move the measure's value for the past twelve months by one percentage point or more, or by 5% of its value, whichever is smaller. Changes in how a source system records a field, such as the arrival time change, count as changes to the measure, because the measure moves even if no one touched its code.

Change Procedure

A change is treated as an event with a procedure around it. The requester submits a change form describing the reason. The steward recomputes the past twelve months under both the old and new definitions and reports the difference. If approval is needed, the committee considers the request at its next monthly meeting. Once a change is approved, recipients of every report that includes the measure receive notice at least 30 days before it takes effect, naming the measure, the change, the expected shift and the effective date. For the first three months after the change, reports show the measure under both definitions side by side. Kahn et al. (2016) emphasize conformance between data and their stated definitions as a basic dimension of data quality, and dual reporting is how Northgate will keep readers able to tell a change in definition from a change in performance.

Disputes

Disputes will happen, and they need a route. If a requester and an owner disagree about a change, the steward first prepares the two-definition comparison and meets with both. If they still disagree, the committee chair decides within 30 days. If either party believes the decision affects patient safety or regulatory reporting, the chief medical officer or chief operating officer, as appropriate, makes the final decision within a further 30 days. A measure under dispute keeps its current definition until the dispute is resolved.

Historical Reporting

When a definition changes, historical figures are restated under the new definition for the previous 24 months wherever the data allow. Where they cannot be restated, for example because a field did not exist, trend charts will show a visible break at the effective date with a note explaining it, and the two periods will not be joined by a line. No report will silently mix values computed under different definitions. Berwick et al. (2003) argue that measurement supports improvement only when users trust and understand it, and an unmarked break in a series undermines exactly that.

Implementation

Enterprise analytics will assign owners and stewards to the 46 measures in current recurring reports by December 15 and bring the list to the committee for confirmation. The change form and log will be live by January 1.

Approval Routing

This memo goes first to the analytics committee for adoption, then to the chief operating officer for endorsement, and finally to the executive quality council for information. Once endorsed, it will be added to the analytics policy manual.

References

Berwick, D. M., James, B., & Coye, M. J. (2003). Connections between quality measurement and improvement. Medical Care, 41(1 Suppl.), I30-I38. https://doi.org/10.1097/00005650-200301001-00004

Holmes, J. H., Elliott, T. E., Brown, J. S., Raebel, M. A., Davidson, A., Nelson, A. F., Chung, A., La Chance, P., & Steiner, J. F. (2014). Clinical research data warehouse governance for distributed research networks in the USA: A systematic review of the literature. Journal of the American Medical Informatics Association, 21(4), 730-736. https://doi.org/10.1136/amiajnl-2013-002370

Kahn, M. G., Callahan, T. J., Barnard, J., Bauck, A. E., Brown, J., Davidson, B. N., Estiri, H., Goerg, C., Holve, E., Johnson, S. G., Liaw, S.-T., Hamilton-Lopez, M., Meeker, D., Ong, T. C., Ryan, P., Shang, N., Weiskopf, N. G., Weng, C., Zozus, M. N., . . . Schilling, L. (2016). A harmonized data quality assessment terminology and framework for the secondary use of electronic health record data. eGEMs, 4(1), Article 18. https://doi.org/10.13063/2327-9214.1244