Introduction. VCSQI is a voluntary consortium of 17 hospitals and 13 cardiac surgical practices providing open-heart surgery in the Commonwealth of Virginia.  VSCQI’s members perform over 99 percent of Virginia’s open-heart procedures.  The group has convened since 1996, comparing data and exchanging information to improve the quality of surgical care and contain costs.  VCSQI helped design and develop a global pricing demonstration with CMS in 2002 and participated in the adoption of quality measures in cardiac surgery for the National Quality Forum in 2005.

Goals and Objectives.  VCSQI’s goal is to improve clinical quality across the state in heart surgery programs of all size through outcomes analysis and process improvements.  VCSQI members are enabled with a unique database linking clinical and financial outcomes.  The group believes that through a focus on quality, cost containment in cardiac surgical care can be achieved.  The incidence of complications will decline and efficient resource use will be encouraged.

Members’ primary focus is quality improvement (QI).  The collaborative model consists of a process for convening leaders, use of technology for regional information sharing, educational programs to replicate best practices, and systems change to improve care processes.  The objective is to help members effectively redesign clinical processes and modify provider behavior using the best evidence available.  While maintaining a focus on quality, opportunities are created to make better use of resources and contain costs.

Accomplishments.  VCSQI participants consist of surgeons, administrators, nurses, outcomes specialists, and data managers.  An information system has been built combining standardized clinical data from the Society of Thoracic Surgeons (STS) with financial data to identify QI opportunities and track change.  The group has worked with CMS, the National Quality Forum, Wellpoint, and STS in various initiatives.  A protocol for reducing the incidence of post-operative atrial fibrillation has been in the field since 2005.  VCSQI has developed a quality dashboard tied to a pay-for-performance program and gain-sharing models aligning incentives for physicians, hospitals, and payers.  VCSQI is a working model for regional health information sharing, a grass-roots quality improvement organization, and a patient safety collaborative.

VCSQI Information System. VCSQI retained the Armus Corporation to develop a data repository now populated with nearly 40,000 records from 15 hospitals dating from 2001 to 2007.  Members submit patient data for all adult cardiac surgeries semi-annually to the web-based system.  Clinical data from the STS Adult Cardiac Surgery database are mapped with financial data from standardized hospital UB-92 files.  Ratios of cost-to-charges are used to create ‘normalized’ charges.  An Application Library, Annual Chart Book, Technical Manual, and Data Quality Assurance plan have been developed.  Components of the application library include procedure volume, patient demographics, risk factors, post-operative complications, operative mortality, resource use, costs of care, performance reports, valve device use, special topics, and missing values reports for data quality checks.

Quality Improvement Model.  VCSQI focuses on high-risk patients and high-cost procedures to uncover performance variations in operative mortality, post-operative complications, and resource use.  Risk-adjusted operative mortality and incidence rates for 6 post-operative complications have been a starting point for consensus formation on protocol development and adoption.

The concurrent processes driving members’ involvement include: validating the comparability and quality of clinical/financial data, analyzing patterns and trends in outcomes and process measures, defining best practices, and replicating these best practices to improve outcomes.  The working groups include a Quality Committee, a Demonstration Committee, a Writing Committee, and the Board of Directors.

Data Quality Assurance – The focus is on improving the timeliness, consistency, and quality of data reported and uploaded into the data repository.  Accurately capturing and reliably reporting clinical performance indicators is the cornerstone to a QI infrastructure.  It is important to ensure comparable data from one time period to the next, across facilities, and between different datasets.  A data quality assurance process is a means to judge inter-rater reliability in data capture and quantify errors and inconsistencies.  This is an iterative process of measuring, educating, and improving data quality.

Performance Indicator Review and Development – Here attention is on the development, refinement, and use of selected clinical quality indicators to be used to measure performance and, ideally, reward performance. Using a set of clinically relevant indicators tied to care processes which can be altered easily and quickly is a priority.  As multiple change attempts are initiated, an expanded measurement set will evolve.

Best Practices – The focus is on ways to identify, document, replicate, and evaluate the implementation of best practices in specialty areas associated with cardiac surgical care.  Some best practices involve cross-cutting clinical issues and re-defining links across organizational boundaries.  VCSQI convenes physician leaders, nursing executives, and program administrators for the purpose of engaging all relevant staff and encouraging widespread adoption of a best practice.  The approach used is to:

• Help participants define quality improvement objectives and plans;
• Set agendas, host regular communications, publish minutes and outcomes;
• Maintain contact names and documentation;
• Host conferences to stimulate the exchange of ideas and buy-in;

• Convene steering groups and facilitate their work;
• Shape consensus and resolve differences;
• Stay in regular contact with participants;
• Listen, collect feedback and provide synopses and input for the evaluation process.
  

Benefits:  Many QI efforts lack the right collaborative methodology and resource intensity to change clinical practices in meaningful ways.  VCSQI’s model has durability and established proof of concept.   Dialogue among clinicians and hospitals is not externally imposed; it is self-motivated.  A data repository and QI process are the cornerstones to a successful statewide network.  Benefits to members include:

• Involvement in a multi-disciplinary, peer-to-peer model where dialogue promotes buy-in and encourages adoption of successful quality improvement efforts;
• Development of a quality indicator dataset that is integrated into a single repository, eliminating the silo approach to data management;
• Consistency in data aggregation, reporting, documentation, and quality assurance;
• A means to document evidence of systems change and practice standardization;
• Potential for savings from quality improvements tied to better patient outcomes, efficient use of resources, and aligned performance incentives;
• A comprehensive plan to bring all physicians to the level of data collection, reporting, and performance improvement that will lead to system wide quality improvement and sustained reductions in cost of care for all patients;
• A model extensible to practices and heart programs in other areas.

Bottom Line: VCSQI members have a unique database and a progressive agenda.  Dialogue on quality improvement is aligning providers’ incentives and furthering positive working relations between physicians, administration, and payers.  Developing a successful quality improvement effort requires access to leading technology, effective group processes, sound communications, vigilant data quality assurance, proven measures and methods, documented systems changes, timely strategic thinking, and resourceful use of diverse assets.  Topping the list is an overriding sense of purpose, trust, and an appetite to make major accomplishments.

 

Recent Organizational Accomplishments

VCSQI has made solid strides in 2007.  Hospitals, continuing to upload data into the Armus data repository, now have nearly 40,000 cases (25,000 CABGs) dating from 2001 through the first half of 2007.  Annual Chart Books of hospital-specific process and outcomes measures and statewide norms are produced from this database.  The Quality Committee circulates case studies and ‘missing values’ reports to maintain vigilance over data integrity.  The Committee provides a valuable clearinghouse function for members posing questions and discussing various clinical issues among peers across the state. 

In the quality improvement arena, VCSQI continues dialogue on the  costs of post-operative complications, the efficacy of its atrial fibrillation prevention protocol, ways to improve accurate measurement of blood product use, early extubation practices, transfusion criteria (and the risks associated with transfusing patients), and the recent increases in the prescription of anti-lipids at discharge.  Reducing rates of post-operative renal failure, identifying the reasons behind reductions in the incidence of deep sternal wound infections in CABG patients, and profiling patients with metabolic syndrome are also generating interest.  Additionally, VCSQI undertook these actions in 2007:

• Governance – The Board of Directors updated its bylaws placing more emphasis on member participation criteria.  They are championing the development of an internal report card to stimulate site visits and improve outcomes among less optimal performers (see section below).
• New Members – The Bon Secours Maryview Heart Institute became a VCSQI member in 2007 along with new surgical practices established in Salem and Richmond.
• Conference – VCSQI participated in UVA’s “50 Years of Progress in Cardiovascular Surgery” conference on August 24-25, giving presentations on the aprotinin dilemma, blood use, and a debate on the efficacy of CABG surgery versus PCI procedures.
• Proposal – Submitted to the Centers for Medicare and Medicaid Services (CMS) for inclusion in their “MMA 646 Gainsharing Demonstration” was a proposal to use the VCSQI database to reduce variations and create savings.  (The proposal was not accepted.)
• Early Extubation – Three site visits were conducted and documentation produced on successes members were having in timely extubation of patients and reduction in rates of prolonged ventilation.
• Atrial Fibrillation Prevention Protocol – An article on an atrial fibrillation prevention protocol was published in an STS online newsletter.

 

Earlier topics covered by the group include study of physician-specific resource use, race and gender differentials in outcomes, a statewide zip code depiction of procedure volume, review of Medicare’s SCIP program, preventing deep sternal wound infections, comparison of patient risk calculation methods, generating the NQF measures for Virginia, providing Wellpoint surgeons’ input to the QP3 pay for performance program, and effective management of diabetic patients.

Further Opportunities and Directions for Growth

Beyond exploring the contents of VCSQI’s clinical data and encouraging the overhaul of care processes to improve post-operative outcomes, there are other avenues for applying resources.  Some candidates include:

• Financial data – The systematic mining of the UB-92 data and refinement of methods for estimating costs from charge data deserves more attention;
• Economic consequences – Engaging financial officers, administrators, and surgeons in better managing resources and creating savings models tied to quality improvement is an avenue for aligning incentives;
• Data robustness – Submitting clinical data closer to ‘real-time’ can improve the sentinel role of the database; comparisons between similarly-defined clinical and administrative indicators can flag inconsistencies;
• Longitudinal tracking – Tying STS data to ACC, HCUP or other claims data can provide glimpses of patient care beyond the inpatient stay;
• Epidemiological and translational research - A near 100 percent sample of cardiac surgeries in Virginia lends itself to regional comparisons, demonstration trials, and special studies in collaboration with NIH, AHRQ or CDC;
• Replication potential – Marrying VCSQI’s collaborative process to the gold standard in clinical data (i.e., the STS database) serves as a model for replicating quality improvement work in other clinical specialties.

Proposed Outcomes & Performance Improvement Initiative

Physician and administrative leaders in VCSQI propose going beyond simply documenting and hoping for passive diffusion of best practices in cardiac surgery.  The intent is to actively spearhead a voluntary outcomes improvement initiative where a team will follow a specified methodology and introduce a new set of care processes into an under-performing environment.  Attributes of the intervention would include a clearly defined focus and set of objectives, a sound evidence-basis, a timeline, budget, and team structure.  The peer-reviewed statistical model for determining impact may more closely resemble a multi-site clinical trial format.  Documentation from this initiative would better define return on investment and savings potential.  Better outcomes would result at the intervention site and have a positive influence on the VCSQI statewide average.  Most importantly, process change would be accelerated.

Model.  The VCSQI Implementation Committee responsible for designing the outcomes improvement initiative, implementing the first stages of the effort, and beginning an actual intervention will employ the following model:

• Setting priorities – The first step is to identify priority topics for prospective intervention work;
• Dashboard – A set of general and specific outcomes indicators will be selected for tracking a particular outcomes improvement initiative; the STS hospital-specific star rating system for clinical processes, morbidity, and/or mortality could augment other more-specific measures;
• Periodic reporting – A blinded, de-identified ‘report card’ with specific indicators will be circulated periodically to key participants;
• Identifying best practices and under-performers – The report card and VCSQI database will be used to set threshold values for identifying consistently strong (i.e., ‘best practice’ performers) and under-performing providers;
• Scientific basis – A systematic review of the scientific literature will be conducted as a means for assembling defensible evidence of a best practice care process;
• Protocol – A study methodology will be developed to test the statistical significance of changes in key indicators; there may be a need to define custom fields in the VCSQI database;
• Confidentiality – A policy will be adopted on the exchange of confidential information, non-disclosure by team members, and blinding comparative data;
• Communications – A plan for communicating externally and among team members will be used to facilitate shared decision-making and accountability;
• Project management – The operational details, budgeting of resources, timeline, and management structure will guide intervention activities;
• Documentation standards – A template will be employed for capturing qualitative information, data, and other details of the intervention efforts;
• Incentives – An agreed-upon set of benefits and rewards will serve as unifying and motivating force to guide joint efforts.

Intervention.  Elements of the outcomes improvement intervention include the following:

• Identifying and engaging the key clinical and administrative leaders affected by a specific redefinition of clinical processes;
• Creating an intervention team with defined roles and responsibilities that may extend beyond traditional organizational boundaries;
• Educating participants on the nature and benefits of the redesign effort;
• Adapting a generic process improvement to fit the context of the intervention site;
• Involving and educating patients to improve adherence and reduce variances;
• Documenting the barriers and constraints encountered that affect the change effort;
• Using a feedback loop to ensure timely communications and performance tracking during the various stages of program design and implementation.

Resource Requirements and Next Steps.  The resources required for this undertaking will be detailed by the VCSQI Board of Directors and Committees.  The study protocol will be tailored to the specific high-priority performance improvement topics identified by the VCSQI leadership.  The time line will begin with an interval for data collection and analysis, review of scientific literature, external peer review, and creation of a core workgroup.  External funding sources may be approached to secure additional support for the initiative.

VCSQI Contact Information:

Alan M. Speir, M.D., Chairman
E-mail:              Click here
Phone:               703-280-5858

Gyula Sziraczky, President, ARMUS Corporation
E-mail:              Click here
Phone:               (800) 94-ARMUS

Edwin Fonner, Jr., DrPH, Executive Director
E-mail:              Click here
Phone:               (913) 888-2179

VCSQI BOARD OF DIRECTORS

Alan M. Speir, MD, Chairman, Falls Church
Paul Frantz, MD, Vice Chairman, Roanoke
Ivan Crosby, MD, Charlottesville
Vigneshwar Kasirajan, MD, Richmond
Denton Stam, MD, Winchester

Jennifer Chiusano, Treasurer, Sentara Norfolk General Hospital, Norfolk
Eileen Dohmann, Mary Washington Hospital, Fredericksburg
Skip Meador, Centra Health, Lynchburg
John Peterman, Riverside Regional Medical Center, Newport News
Edwin Fonner, Jr., DrPH, Executive Director

VCSQI HOSPITAL MEMBERS

Bon Secours Richmond Health System
     St. Mary’s Hospital
     Memorial Regional Medical Center
Bon Secours Maryview Medical Center, Portsmouth
Carilion Roanoke Memorial Hospital, Roanoke
Centra Health (Lynchburg General Hospital), Lynchburg
HCA
     Chippenham & Johnston Willis Hospitals, Richmond
     Henrico Doctor’s Hospital, Richmond
     Lewis-Gale Medical Center, Salem
Inova Health System
     Fairfax Hospital
     Alexandria Hospital
Mary Washington Hospital, Fredericksburg
Riverside Regional Medical Center, Newport News
Sentara Health System
     Norfolk General Hospital
     Virginia Beach General Hospital
University of Virginia Health Sciences Center, Charlottesville
Virginia Commonwealth University Health System, Richmond
Winchester Medical Center, Winchester

VCSQI PHYSICIAN MEMBERS

Bon Secours Heart Institute, Portsmouth
Cardiac Surgery Specialists, Richmond
Cardiothoracic Surgery Associates, Falls Church
Cardiac and Thoracic Surgical Associates, Richmond
Carilion Cardiothoracic Surgery, Roanoke
Centra Health Cardiothoracic Surgery, Lynchburg
Medical College of Virginia Physician Practice, Richmond
Mid-Atlantic Cardiothoracic Surgery, Norfolk
Roanoke Valley Cardiovascular Surgery, Salem
Tidewater Cardiothoracic, Newport News
University of Virginia Health System, Charlottesville
Valley Health Cardiothoracic & Vascular Surgeons, Winchester
VCS, Inc., Fredericksburg