2020 Participation Award Update and PDSA Worksheet - 2 PM EST/1 PM CST/12 PM MT/11AM PT December 15, 2020 Cheryl Jackson, DNP, MS, RN, CNOR, CPHQ ...
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2020 Participation Award Update
and
PDSA Worksheet
December 15, 2020
2 PM EST/1 PM CST/12 PM MT/11AM PT
Cheryl Jackson, DNP, MS, RN, CNOR, CPHQ – SVS PSO
Sheila DeBastiani, R.T. (R), SSGBC, SSCC
WakeMed Health – Raleigh, NC
1
2020 PARTICIPATION AWARD CHANGES 2
Participation Committee • Daniel Bertges, MD – Chair – University of Vermont • Alex Shepard, MD – Ex-Officio – Henry Ford Hospital • Faisal Aziz, MD – Penn St • Cassius Ochoa Chaar, MD - Yale • Amanda Enerson, RN, MSN – Memorial Hermann • Jennifer Farrell, RN, MHCA – Froedtert • Yuming Lin, MSM, CLSS – U of Florida • Susan Nappo, RVT/MBA – Catholic Health Mercy Hospital of Buffalo • Danielle Pineda, MD – Thomas Jefferson • Mel Sharafuddin, MD – U of Iowa • Chris Smolock, MD – Cleveland Clinic • SVS: • Cheryl Jackson – SVS PSO Director of Quality (Facilitator) • Jens Jorgensen, MD – SVS PSO Medical Director • Jim Wadzinski – SVS PSO Deputy Executive Director 3
Participation Award 2020
Scoring since release of Participation Award (pre COVID-19)
• Four categories scored, each on a 0-6 point scale:
o LTFU (weighted 40%)
o Meeting attendance (weighted 30%)
o QI project involvement (weighted 20%)
o Number of registry subscriptions (weighted 10%)
4
COVID-19 Factors
We are aware that COVID-19 has put a significant strain on staff and resources
• Formal announcement sent out April 9, 2020
• Personnel may be reassigned making the performance of usual operations difficult if not
impossible
• Many patients have had their follow-up office visits delayed. Resulting in patients being
seen outside of the prescribed time period (9-21 months) which is beyond anyone’s
control.
• Workflow disruptions will cause delays in data entry and follow-up and VQI plans to
make accommodations as a result.
• All regional meetings were remote attendance only - regional meeting credit given to
those who attended virtually.
• Validation: 2019 selected sites will have 2 years to complete the process
The SVS VQI will do our best to assure that any temporary workflow disruption will not
have a negative impact on SVS VQI work or subsequent participation awards.
Participation Award 2020 UPDATE
MAJOR CHANGE
• Long Term Follow-Up 2018 cases
– COVID-19 affect
– Remove LFTU from the 2020 Participation Award – BUT…
– Acknowledge centers that maintained, improved LTFU with a certificate
• Centers in top 25% for 2018 LTFU rates
• Statistically significant increase in LTFU rate from 2017 to 2018
6
Participation Award 2020 – Regional Meeting
Attendance
Current Regional Meeting Attendance Criteria
• Each regional meeting will be scored on a 0-3 point scale/regional meeting
– Only remote meetings offered due to COVID-19. Attendance points rewarded.
– For centers with 3 or more MDs, 1 point for each MD attending, up to a max
of 3 points
– If site has only 2 MDs and 1 attends, 2 points
– If site has
Participation Award 2020 - QI Project Domain
Scoring on 0 – 6 point scale to keep consistent with other measures
– Initiation of a QI Project, evidenced by submitting a Project Charter
– Presenting a QI Project (presentation or poster) at a Regional VQI,
*Regional Society Meeting, or Hospital Board Meeting
– Presenting a QI Project (presentation or poster) at the National VQI or
*Vascular Annual Meeting
– *Publish VQI based article in a Peer Reviewed Journal
• 6-point maximum credit for QI even though additional points can be acquired
• Each VQI center submits one QI project per center for the Participation Award
* Please send attestation (proof) to cjackson@svspso.org on or before
December 31, 2020.
8
Quality Improvement Domain:
Activity Documentation Score
1. QI Project Initiation Attestation to include: 2 points -
• QI Project Title Can be submitted
(Charter) • Problem Statement at any time
• Project Leader
• Clinical Sponsor
• Expected start date
• Goal Statement and Metrics
• Blank charter
https://www.vqi.org/resources/quali
ty-improvement/ (Last link in the
center of the page)
• Project charters should be emailed
to QI@SVSPSO.ORG or
9
cjackson@svspso.org
Quality Improvement Details:
Activity Documentation Score
Presentation of QI a. PSO Staff will document presentations at 2 points
project/research at one of VQI Regional Meetings.
the following: b. Sites will be asked to submit the Due on or before
a. VQI regional meeting evidence of presentations/posters at 12/31/2020
b. Regional Society meeting Regional Society meetings or their
c. Center-level Board center’s Board meeting.
meeting • Regional Society presentations/posters
should be emailed to QI@SVSPSO.ORG or
cjackson@svspso.org
10Quality Improvement Details:
Activity Documentation Score
Presentation of QI • PSO Staff will document 2 points – for
project/research at one of presentations/posters at the National VQI completion of option
the following: Annual Meeting. a or b.
a. National VQI Annual • Sites will be asked to submit evidence of
Meeting the presentation/poster at the Vascular Due on or before
b. Vascular Annual Meeting Annual Meeting. 7/31/2020
• Vascular Annual Meeting
presentations/posters should be emailed
to cjackson@svspso.org
11Quality Improvement Details:
Activity Documentation Score
Publish VQI based article a. Letter of acceptance for publication 2 points – for
in a Peer Reviewed b. Draft of article submitted for publication completion of option
Journal a or b.
Due on or before
12/31/2020
12Participation Award 2020
Improvement of rates or maintaining excellent performance rates
on National QI Initiatives
• Any hospital that shows a statistically significant improvement
in either its rate of EVAR LTFU imaging or DC medications from
the prior year to the scoring year will receive one point per
measure.
• Any hospital that was at or above the 75th percentile for either
measure in the prior year will get one point per measure if it
remains at or above the 75th percentile in either measure in
the scoring year, as long as either of its rates has not gotten
significantly worse.
13Participation Award 2020 – Registry Subscriptions
Registry Subscriptions
1-2 registries = 0 points
3-5 registries = 2
6-8 registries = 4
≥ 9 registries = 6
• If the center is a vein-only center (i.e. could only possibly
subscribe to 1 registry) = 1 point
14Participation Award 2020 Update
Scoring 2020 (During COVID-19)
• Three categories scored, each on a 0-6 point scale:
o LTFU – REMOVED. Separate recognition.
o Meeting attendance (weighted 50%)
o QI project involvement (weighted 40%)
o Number of registry subscriptions (weighted 10%)
• The final score is calculated as follows:
Total points = 5 x Attendance score + 4 x QIP score + 1 x Registry score
15Star Points:
A total of 60 points can be earned. Points needed for
each Star level are as follows:
• 0 Stars < 17 points
• 1 Star 17-26 points
• 2 Stars 27-40 points
• 3 Stars > 40 points
16Participation Award 2020
Other Criteria
• NO star award if no one from a center attends either meeting
(Spring and Fall), regardless of total points
17Validation of your participation for 2020
• LTFU
– Provided by VQI
• Attendance at Regional Meetings
– Spring (Date): who attended
– Fall (Date): who attended
• Submitted QI Project Charters
– Date submitted and topic
– Presentation/Publication of QI Projects using VQI data
• When, where, title of presentation
• Number of registries
– Provided by VQI
Send to cjackson@svspso.org
18Marketing Your Participation Award
• PSO limitations
– Not allowed to publicly report any outcomes data, which is the primary
reason we have a Participation Award and not a Quality/Outcomes Award
– This is a Participation Award and should not be interpreted or positioned
as a direct indicator of the quality of care provided by your institution
– The Participation Award is linked to critical activities that shows a center’s
commitment to quality improvement and patient engagement, but the
award is not and cannot be referenced as an indicator directly tied to
quality of care
– Cannot be used for competitive marketing purposes
– Data from the SVS VQI/SVS PSO can never be used for punitive purposes
– Sites receive a Participation Award certificate for 1, 2, and 3 stars
– We provide a standard press release when the awards are released
19Call for VQI Poster Abstracts
for the 2021 VQI Annual
Meeting
202021 Poster Abstract Information
Where: San Diego Convention Center – San Diego, CA
When: Tuesday, June 1, 2021 12:00PM – 6:30PM*
Wednesday, June 2, 2021 8:00AM – 5:00PM
*Poster Presentation and Networking Reception – Tuesday, June
1st at 5:00PM to 6:30P
212021 Poster Abstract Information
• Planning on an in-person meeting
• The protection and safety of our attendees remain our top
priority
• If needed, we will once again convert the meeting into an all-
virtual format
• Incorporating some aspects of virtual online learning
• Posters that were accepted for 2020 will automatically be
accepted into the 2021 poster session without the need to
resubmit
22Showcase you and your center’s work!!
Opportunity to present your work in quality improvement and
research utilizing VQI data
• Target audience:
– Vascular surgeons and interventional providers
– Data managers/abstractors
– Nurses, NPs, PAs
– Quality improvement professionals
23Poster Abstract Submission
Key Dates for Abstracts:
• Abstract submission deadline: February 7, 2021 at 3 p.m. CT
• Notification of acceptance: March 1, 2021
• Poster details will be provided when an abstract has been
accepted.
24Poster Abstract Submission Guidelines Poster Submissions for Quality Improvement Projects should include: • Problem Statement • Goals • Improvement Strategies • Results • Challenges/Lessons Learned • Success Factors 25
2021 Poster Abstract Information
Poster submissions for Research projects should include:
• Objective/Introduction
• Methods
• Results
• Conclusions
26Poster Abstract Submission
Reminder - Key Dates for Abstracts:
• Abstract submission deadline: February 7, 2021 at 3 p.m. CT
• Notification of acceptance: March 1, 2021
• Poster details will be provided when an abstract has been
accepted.
27Past Posters and Presentations
2019 VQI@VAM Posters on the VQI Website
https://www.vqi.org/national-data/vqi-annual-meeting-2019-june-11th-poster-
session/
2020 Virtual VQI Annual Meeting Presentations
https://www.vqi.org/national-data/
• Both are located in the Members Only section of the www.vqi.org website
– For the Members Only section a separate log-in and password is needed. Contact Jen
Correa at jcorrea@svspso.org for access.
Multiple abstracts can be submitted from one author, center, or region.
28Questions will be answered after the presentation! Type questions in the Question Box 29
PRESENTATION
PDSA WORKSHEET
Sheila DeBastiani, R.T. (R), SSGBC, SSCC
WakeMed Health – Raleigh, NC
3031
Identifying a QI Project
• Use your VQI reports
– Bi-annual reports (Spring and Fall)
– Center Opportunity Profile for Improvement
(COPI) reports
• Center level
• Physician level
– Analytics engine reports
– SVS guidelines and recommendations
33Starting a QI Project
WPP Vascular Surgery LTFU
Team members
• Project lead: Sheila DeBastiani, WakeMed VQI Site Manager
• Project sponsor: Amanda Thompson, Executive Director, Heart & Vascular
Services
• Quality expert: Eileen Ramos, Quality Analytics
• Front line staff:
o Stephanie Prell, Practice Nurse
o Debbie Slayton, Practice Manager
o Debbie Jones-Coombs, EPIC Analyst
o Krystle Green, EPIC Analyst
• Stakeholders:
o Steven Kagan, MD
o Joseph Salfity, MD
34SMART Goal/Aim Statement
Aim Statement: WHAT YOU ARE TRYING TO ACCOMPLISH ?
• Specific- What specifically will you do?
• Measurable- what to measure/how will you know if you
meet your goal?
• Achievable- brief plan to accomplish your goal
• Relevant- why is it important to do now?
• Time Specific- what is the anticipated length of time to reach
your goal?
35Methodology 36
37
FOCUS 38
39
40
41
42
WPP Vascular Surgery Scheduled LTFU Office Visits
% of patients scheduled within window
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Baseline Sep-20 Oct-20 Nov-20
43Quality Improvement Details:
WakeMed Health & Hospitals
Raleigh Campus
VQI Project Charter: LTFU Visits
Project Overview
Problem Statement: The July 2018 issue of the Journal of Vascular Surgery published recommendations for long term follow-up (LTFU) care
for patients receiving open and endovascular surgery arterial procedures. The purpose of LTFU is to "detect clinically significant problems at
an early stage when they can be managed most safely and effectively, even before clinical signs and symptoms are evident." (1) The VQI
defines long term follow-up (LTFU) as patient contact 9-21 months after the procedure date. Review of LTFU quality metrics revealed 53% of
WPP Vascular Surgery patients for combined registries whose procedures were completed between January 1, 2019 and December 31,
2019, were scheduled and/or seen in the office for LTFU care.
Goal: 80% (or greater)of patients are seen within 9-21 months for LTFU post op (national goal). The period of evaluation will be June 1 2018-
June 31, 2019.
Scope: Total applicable procedure volume entered into the VQI database for procedures completed within the identified timeframe.
44Quality Improvement Details:
Deliverables:
• Communication to WPP Vascular Surgery on patients who fall within the LTFU VQI defined time period of 9-21 months: Data
abstractor will provide a master list of patients accessible to WPP Vascular Surgery Office Staff on a shared drive to identify VQI
patients and to track status of LTFU office visits.
• Patient education on importance of LTFU care: WPP Vascular Surgery will include a section in the patient pre-op instructions that
emphasizes the importance of scheduling the LTFU visit
• Standardized process for scheduling LTFU office visits for all post op/post procedure patients: The Practice Manager will
share the list of patients for LTFU visits with identified physician specific Patient Account Representatives (PARs)
o PARs will be responsible for updating the physician’s list and scheduling appointments.
§ LTFU visit will be scheduled when the patient is in the office for their post op or 6 month office visit
§ Patients who cancel or are “no shows” will be called by the PAR the first two weeks of each month to reschedule
• Standardized process for conducting phone interviews with patients who cancel/ do not show for LTFU appointments,( who
may have the potential to be lost to follow-up):
o WPP Vascular RN will call attempt to call all patients who have not made an appointment/canceled/or are a no show in the 18-21
month post procedure window
§ Dedicated time for phone calls is the third Friday of each month
§ EVAR/Complex EVAR/AAA patients will be encouraged to make an appointment for imaging to evaluate sac diameter
§ If a patient is unable to schedule the LTFU, the Vascular RN will interview the patient while on the phone and complete the VQI
LTFU mandatory fields in EPIC
§ If unable to contact and/or interview the patient, the Vascular RN will use EPIC dot phrase to document the patient is lost to
follow up
• Standardized documentation in EPIC:
o EPIC Analyst will provide Tip Sheet to the Vascular RN on how to access LTFU VQI Add-ons in EPIC
o EPIC Analyst will assist vascular RN with utilizing a dot phrase in EPIC to document patients who are lost to follow-up
• Monthly review of compliance sent to WPP Vascular Surgery:
o Data Abstractor and VQI Site Manager will send compliance report at the end of each month, beginning August 2020
o Monthly meetings with Project Team to assess new processes and make recommendations for improvement
Resources required: Work flow chart to document process for scheduling LTFU visits and process for telephone follow ups;
Education for office staff on change in practice for scheduling LTFU office visits; Education (EPIC Tip Sheets)for RNs and Physicians
on accessing EPIC VQI LTFU smart texts; Spread sheet accessible to office staff to identify VQI patients; Scripted EPIC dot phrase for
documentation of patients who are lost to follow up; Updated patient pre-op instructions to include importance of keeping LTFU
appointments
45Quality Improvement Details:
Key Metrics Milestones
Outcome Metrics: Milestone/Description Date: (mm/yy)
Completion of 80% or greater VQI required data elements for
LTFU patient assessments, either in office or by telephone
across each of the VQI registries between 9 and 21 months
post procedure. Complete QI Project Charter June 2020
Review baseline data by procedure June 2020
Identify barriers, Root Cause Analysis June-July 2020
Process Metrics: EPIC documentation to include LTFU office
visit, follow-up phone visit completed by RN, or patient lost to
follow-up Identify potential improvements July 2020
Implement Changes; provide training August 2020
September-
Monitor changes November 2020
Present to Vascular Services Quality Meeting to
expand project to all WPP specialties performing
vascular procedures; February 2021
Team Members
Clinical Sponsor: Steven Kagan, MD (WakeMed Vascular Services Quality
Chair); Joseph Salfity, MD (WPP Vascular Surgery; Physician Champion for
Executive Sponsor: Charles Harr, MD (CM, Raleigh Campus) TCAR/CAS Registry)
Sponsor: Amanda Thompson, RN (Director Heart & Vascular
Services, Raleigh Campus) Process Owner: Sheila DeBastiani
Project Leader: Sheila DeBastiani (VQI Site Manager)
Team Members:
Eileen Ramos (Quality Analytics) Deborah Jones Coombs (EPIC Analyst)
Debbie Slayton (WPP Vascular Surgery Practice Manager) Krystle Greene (EPIC analyst)
Stephanie Prell, RN (WPP Vascular Surgery RN)
References:
(1) "Recommendations for Follow-up After Vascular Surgery Arterial Procedures, 2018 SVS Practice Guidelines" retrieved from https://vascular.org/sites/default/files/SVS_Guideline_Follow-up_Overview.pdf
46Next Steps
Collaboration with Cardiac & Vascular Quality:
P2Y12 Plavix, Brillinta, Effient or
Aspirin
Statin
Schedule LTFU Office Visit
(DRAFT)
47Next Steps
• Review patients within the window who do not have
appointments scheduled: Was the patient an in-
patient at the time their procedure was scheduled?
• Determine if patients are cancelling appointments/no
shows because they cannot afford transportation:
Collaborate with Community Health to enroll in their
Free Ride Program.
• Reach goal of 80% or greater: Roll out to other
practices.
48References
• Plan Do Study Act (PDSA) Form (ahrq.gov) December 1,
2020, retrieved from
https:www.ahrq.gov/sitedefault/files/wysiwygl/evidencenow/
tools-and-materials/pdsa-form.pdf (December 1,2020)
• WakeMed Health & Hospitals
Kaizen Promotion Office 2020
• "Recommendations for Follow-up After Vascular Surgery
Arterial Procedures, 2018 SVS Practice Guidelines" June 15,
2020, retrieved from
https://vascular.org/sites/default/files/SVS_Guideline_Follow-
up_Overview.pdf
49Questions? 50
51
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