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Quality Initiatives to Change the Work Culture and Outcomes at a Local CCL ? Five Practical Suggestions for Quality Vietnam National Congress of Cardiology October 13, 2014 Charles E Chambers, MD, FSCAI, FACC, NCRP President, Society for Cardiovascular Angiography and Interventions Professor of Medicine and Radiology Pennsylvania State University College of Medicine Director, Cardiac Catheterization Laboratories MS Hershey Medical Center, Hershey, PA Society for Cardiovascular Angiography and Intervention 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 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 Comparisons, Identify Quality Concerns STEP 8: Implement PlanDo-Check-Act Cycle STEP 1: SCAI position paper on cath lab quality (www.scai.org, under header bar “guidelines and quality” select “guidelines”, access link to article under “2011, May”) 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 All cardiac catheterization laboratories should have a Quality Committee that interacts with the Hospital Quality committee but meets and performs their functions independently Recommendation 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 COR LOE I C ACC/SCAI 2011 PCI I C Guidelines Update IIa C 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 Regular Meetings (monthly) Identify metrics of care to be monitored (from NCDR reports) Review all serious adverse events (e.g., death, emergency CABG) Perform random film audits (e.g., case per MD for appropriateness, adequate imaging, outcome) Review data on process and outcome metrics Identify quality issues (e.g., any complication with frequency > 90th ile of peer hospitals) (e.g., any physician with outlier incidence of complications) Develop remediation plans, oversee implementation, check results (i.e., plan/do/check/act cycle) Refer larger issues for appropriate intervention (e.g., disruptive physician behavior referred to department director) Responsibilities of the Cath Lab Quality Committee 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 following Outcomes • Structural Domain – Hospital and cath lab structure, Credentialing , Educational Efforts • Process Domain – Monitoring patient , System related, Guidelines related, Cost/Utilization • Outcomes Domain – 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? Both fruit • 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 but not the same • 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 #3 Identify a Database or Method to Capture Data In the US, NCDR’s Cath/PCI Data Registry is easiest solution: 85% of cath labs use cath PCI Registry Quarterly reports summarize institution’s data Results are compared to all hospitals Trends are evident over time Problem areas are easily identified (e.g., >90th %’tile complication rate) Mortality data is risk adjusted 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? 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”, 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 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 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 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 • Internal Review Internal vs External Peer Review – Large enough MD Pool – Rotate Membership – Unbiased/No secondary agendas • External Review – Considered the best assurance for an unbiased and accurate review • No established data for this • Guidelines not specify which is required and therefore should be individualized to the lab, health system, and/or state #5 Conferences and Cath Lab QI • Invasive Cardiology Morbidity and Mortality (Cath Lab M&M) – Separate from clinical cardiology M&M – Open review and assessment of cath lab complications and inhospital events following invasive cardiovascular procedures • 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 1http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=311&ProgramId =1; accessed February 28, 2011 2http://www.acgme.org/outcome/implement/complete_PBLIBooklet.pdf; accessed March 1, 2011 Cath Lab M&M • 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 1Bashore TM, et al 2012 ACCF/ SCAI: Expert Consensus n Cardiac Catheterization Laboratory Standards Update J Am Coll Cardiol 2012;59:2221-2308 2Levine 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 Invasive Case Review Conference  Assure indications for invasive procedures and intra-procedure decisionmaking conform to guidelines  Permits learning from others’ routine cases, not just complication cases  Independent criteria provide objective quality measures ◦ ACCF/SCAI Cath Indications1 and PCI Appropriateness Criteria2  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 1Patel 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;59:1-33.2P 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 Catheterization Lab Educational Conference • 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 discussions • Sign-in sheets; Obtain CME credit CME credit ! Now, How Can This Functioning Quality Assurance/ Quality Improvement Program Be Implemented and Effective? • QA/QI Components – Clinical Proficiency Review – Peer Review – Equipment Performance ■ QA/CQI Committee ■ Data collection process ■ ■ ■ ■ ■ Direct patient-care related indicators System-specific indicators Guidelines-driven indicators Cost-related indicators Outcome-related indicators ■ Physical/Service SCAI QI Toolkit The Society for Cardiovascular Angiography and Intervention Quality Improvement Toolkit (SCAI-QIT) There is Help! SCAI QIT Outline • Defining Quality in the Cath Lab • Operator Requirements • Staff Requirements • Procedural Quality – Benchmarking – Key conferences • Cath Lab Best Practices • Facility and Environmental Issues Cath Lab Accreditation 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 http://www.cvexcel.org 22 What is ACE ? 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