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


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 > 90th 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)


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:
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


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


• 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 do 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

1 />
=1; accessed February 28, 2011
2 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
.
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.