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Mission Statement SCAI promotes excellence in invasive and interventional cardiovascular medicine through physician education and representation, and the advancement of quality standa

Quality Initiatives to Change the Work Culture and Outcomes at a Local CCL ?

Five Practical Suggestions for Quality

Vietnam National Congress of Cardiology

MS Hershey Medical Center, Hershey, PA

Mission Statement

SCAI promotes excellence

in invasive and interventional cardiovascular medicine through physician

education and representation, and the advancement of quality standards to enhance patient care

Society for Cardiovascular

Angiography and Intervention

Quality Initiatives In The Cardiac Catheterization Laboratory of America

STEP 1: SCAI position paper on cath

lab quality cited below

STEP 2: Assemble Cath Lab

QI Committee

STEP 3: Determine Which Quality

Measures to Follow

STEP 4: Identify a database

or method to capture data

STEP 5: Develop Plan to Capture Data

STEP 6: Analyze Data

STEP 7: Using Benchmark

Five Practical Suggestions for Quality

#1 CREATE a Quality Assurance/

Quality Improvement/Peer Review

Programs For all Cardiac

Catheterization Labs

#2 ASSESS Structures, Processes,

and Outcomes

#3 ESTABLISH database, analyze

data, with corrective action when

required

#4 PERFORM Case Peer Review

#5 CREATE Conferences

#1 A Quality Improvement Program for all Cath Laboratories

Every PCI program must have a quality

improvement program that routinely: a) reviews

quality and outcomes of the entire program; b) reviews

results of individual operators; c) includes risk adjustment; d)

provides peer review of difficult or complicated cases, and; e)

performs random case reviews

Participation by every PCI program in a regional or national

PCI registry for the purpose of benchmarking its outcomes

against current national norms

Participation by all physicians that perform PCI in the

American Board of Internal Medicine interventional

cardiology board certification and maintenance of

certification program

IIa C

ACC/SCAI

2011 PCI Guidelines Update

All cardiac catheterization laboratories should have a Quality Committee that interacts with the Hospital Quality committee but meets and performs their functions independently

The Cath Lab QI Committee Members

a Chairperson: a physician trusted by all e.g.,

Director of Cath Lab or Interventional the

Physician Champion

b Lab Staff Champion (Staff QA Coordinator)

c Physician Support (Invasive cardiologists)

d Physician Extenders

e Laboratory Support Staff Cath Lab technical

director or chief technologist

f Cath Lab/Recovery Area

g Cath Lab Administrator/Hospital

Administrator

h Consider cardiac surgeons, other

cardiologists, internists, ER physicians & other

representative from hospital QA department,

and IT support

Team work is essential

Responsibilities of the Cath Lab Quality Committee

1 Regular Meetings (monthly)

2 Identify metrics of care to be

monitored (from NCDR reports)

3 Review all serious adverse events

(e.g., death, emergency CABG)

4 Perform random film audits (e.g.,

1 case per MD for appropriateness,

adequate imaging, outcome)

5 Review data on process and

outcome metrics

6 Identify quality issues (e.g., any

complication with frequency > 90 th ile

of peer hospitals) (e.g., any physician

with outlier incidence of

complications)

7 Develop remediation plans,

oversee implementation, check

results. (i.e., plan/do/check/act cycle)

8 Refer larger issues for appropriate

intervention (e.g., disruptive

physician behavior referred to

department director)

Bashore TM, Balter S, Barac A, Byrne JG, Cavendish JJ, Chambers CE, et al.: American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards Update 2012 J Am Coll Cardiol May 8,

2012 as doi: 10.1016/j.jacc.j.jacc.2012.02.010

#2 Quality is much more than just

– Monitoring of outcomes on a regular basis including risk adjusted mortality,

procedure related LOS, fluoro time, etc., complications (30 days) with data sharing and reporting

How is CQI Different?

• Emphasizes processes of care rather than

individual physician performance

• Involves not just physicians, but all members

of the cath lab team and related departments

• Involves many functions in the process not

just those selected for inspection

• Goal: Continuously improve performance,

not just meet guidelines

QA – Identifies a problem (outlier)

CQI – Provides a framework to solve problems,

continuously improve and thereby reduce outliers

but not the same

Both fruit

In the US, NCDR’s Cath/PCI Data Registry is easiest

solution:

1 85% of cath labs use cath PCI Registry

2 Quarterly reports summarize institution’s data

3 Results are compared to all hospitals

4 Trends are evident over time

5 Problem areas are easily identified (e.g., >90th %’tile complication rate)

6 Mortality data is risk adjusted

#3 Identify a Database or Method

to Capture Data

Advantages of Registry Data

• Clinical rather than administrative data

• Standard data definitions (comparing apples to apples)

• Provides data that are: Relevant, Credible, Timely, Actionable

• Can help facilities meet consumer, payer, and regulator demands

for reporting and quality care

• NCDR data audit program - CathPCI Registry 93.1% accuracy

– (Messenger JC, et al JACC 2012;60:1484–8)

Science - tells us what we can do;

Guidelines – tells us what we should do;

Registries - tell us what we are doing

What Are Your Responsibilities Regarding Registry Data?

1 You must be certain your data are correct

a Your support staff understand what patients go

into the registry

b Understand the data definitions

c Make certain there is timely data entry

d Fight for adequate FTE support for data entry

a This should not be an “add-on”, do in your free time

job

b Sometimes difficult to convince the C-Suite of the

importance and value of Registries

#4 Peer Review of Cases

1 Designate prospectively peer review activities

a Case selection: Adverse Outcome and Randomly selected

b Methods of review: Internal, external, both

c Establish relationship with cath lab conferences

2 Conflicts of interest must be addressed with a formal policy

a If unavoidable, manage COI with transparency and objectivity; peer review cannot be used to gain advantage by competing groups

b Peer Review must be fair, unbiased and non-punitive

3 Confidentiality should be maintained for:

a Data regarding procedural outcomes by operator

b Physicians under investigation for quality issues

c Meeting minutes declared as a peer review activity and are

protected from legal discovery

– Considered the best assurance for

an unbiased and accurate review

• No established data for this

• Guidelines do not specify which

is required and therefore should

be individualized to the lab,

health system, and/or state

• Invasive Cardiology Morbidity and Mortality (Cath Lab M&M)

– Separate from clinical cardiology M&M

– Open review and assessment of cath lab complications and hospital events following invasive cardiovascular procedures

in-• Invasive Case Review Conference (Angio Review)

– Open review of random sample of cases – Diagnostic and interventional cases

• Catheterization Laboratory Educational Conference (Cath Conf)

– Regular, frequent, formal educational events

– Focus on cath lab practice and issues

#5 Conferences and Cath Lab QI

1 http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=311&ProgramId

=1; accessed February 28, 2011

2 http://www.acgme.org/outcome/implement/complete_PBLIBooklet.pdf ; accessed March 1, 2011

• Review adverse events, learn from others’ mistakes

• Identify cath lab structure and process problems

• Improve communication among cath team members

• Educate staff, trainees, and operators Avoid blame!!

 How to Identify Cases for Review:

◦ Develop unbiased system with all major complications presented

 Attendance: all cath lab physicians, trainees, practitioners

 Rules of Conduct:

 Declare the conference to be a peer review session

 Responsible MD should be present when case reviewed

 QI problems needing action should be referred to the QI Committee

Cath Lab M&M

1 Bashore TM, et al 2012 ACCF/ SCAI: Expert Consensus n Cardiac Catheterization Laboratory Standards Update J

Am Coll Cardiol 2012;59:2221-2308 2 Levine GN et al 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary

Intervention A report of the ACCF/AHA/SCAI Cathet Cardiovasc Intervent 2011;73;453-495

 Assure indications for invasive procedures and intra-procedure

decision-making conform to guidelines

 Permits learning from others’ routine cases, not just complication cases

 Independent criteria provide objective quality measures

◦ ACCF/SCAI Cath Indications 1 and PCI Appropriateness Criteria 2

 For less clear case selection or procedures, venue for open discussion

 Non-punitive: the aim is process improvement

 Designate responsible MD (Cath Lab Director) or cath lab manager,

Quality Officer to select random cases for review

 Avoid reviewing a case when responsible MD away

 Keep track of progress (e.g., appropriate indication, number of “normal

coronary” cases, use of FFR) and update the group on progress.

Invasive Case Review Conference

1 Patel MR et al ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 Appropriate Use Criteria for Diagnostic Catheterization J Am Coll Cardiol 2012;59:1-33 2 P atel MR, et al ACCF/SCAI/STS/AATS/AHA/ ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the ACCF

Appropriate Use Criteria Task Force, SCAI, STS, AATS, AHA, ASNC, SCCT J Am Coll Cardiol 2012;59:857-881

• Professional development/education

Required by JCAHO and ACGME

• Introduces new technologies

• Cath Lab Director/Fellowship Director in

charge of conference

• Regular event: weekly, same location

• Use core curriculum to structure topics

• Encourage attendance by non-cath lab MDs –

especially cardiac surgeons, to stimulate

Now, How Can This Functioning Quality Assurance/ Quality Improvement Program Be

Implemented and Effective?

■ QA/CQI Committee

■ Data collection process

■ Direct patient-care related indicators

The Society for Cardiovascular Angiography and Intervention Quality

Improvement Toolkit (SCAI-QIT)

There is Help!

SCAI QIT Outline

• Defining Quality in the Cath Lab

• Cath Lab Best Practices

• Facility and Environmental Issues

What is ACE ?

Accreditation for Cardiovascular Excellence is an

independent, not for profit organization initially

established by SCAI in 2009 with subsequent

partnership from ACC

The mission of ACE is to ensure high-quality patient

care and promote patient safety in facilities

performing invasive cardiac and endovascular

procedures

ACE achieves this mission by setting standards for

quality care, establishing requirements for

accreditation, and providing peer review ACE,

the only cath lab accrediting organization, also

provides tools and resources to support

self-evaluation and quality improvement Visit

22

Cath Lab Accreditation

Final Thoughts and Questions

SCAI is thankful for the opportunity to present our quality initiatives We as a society are dedicated to this effort and enthusiastic in partnering with all

societies, countries, etc., to promote universal application of quality standards for the best possible patient care