How can a Quality Director monitor quality for competing groups?
A famous case in the 1980’s involved a physician who was accused by a Peer Review Committee of sub-standard performance, and had his hospital privileges revoked. The physician sued, claiming members of the Peer Review Committee were seeking to eliminate him as a competitor. At trial, it surfaced that indeed the physicians in the Peer Review Committee had asked the doctor in question to join their practice, and only moved against him when he declined. A large financial penalty was levied against the members of the Peer Review Committee. This created outrage, since doctors claimed (with justification) that they couldn’t serve on performance review committees effectively if they were vulnerable to litigation by doctors with unfavorable reviews. The Wyden bill sought to protect doctors involved in peer review, but was overly broad – it would have sheltered doctors from restraint of trade laws. In the end, the bill was replaced by the Health Care Quality Improvement Act of 1986 which required hospitals to report to the Department of Health any physician who has privileges suspended or revoked for matters of competency, and established a database of, and a clearinghouse of information about, such physicians.
This case illustrates the importance of having a Quality Director who can rise above the concerns and realities of practice – easily said, hard to do. The best solution is for the Director to involve all interested parties in the review processes. If your hospital has multiple practices using the lab, create a Quality Review Committee with membership from each group. Include an independent hospital administrator or nursing director on the committee. Be sure no single group has greater voting power than any other. Use your hospital administrator to mediate solutions to problems, and to adjudicate clinical performance decisions when possible. Keep meticulous minutes, and circulate them for approval. If a performance issue might lead to a restriction of practice privileges, consider arranging an outside review of the issues – independent agreement with findings and proposed solutions would be of great value. The Accreditation for Cardiovascular Excellence (ACE) group can provide peer-review services as well as credentialing services.
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How can a Quality Director get doctors to attend mandatory conferences when physicians are voluntary staff (i.e., not in a faculty practice)?
There must be a “rule” or “bylaws amendment” that states that the doctors involved that they will be ineligible for privileges in the cath lab if they don’t participate in the required activities to maintain quality standards, which includes conference attendance. While this seems like a tough message to deliver, it’s not significantly difference than other requirements to maintain privileges: sufficient CME credits, keeping up to date on charts, and so forth.
The Accreditation for Cardiovascular Excellence (ACE) Guidelines recommends a minimum threshold of 75% attendance at the regularly occurring quality monitoring conference. Excused absences, i.e. on vacation, away at meetings, document emergencies count as meetings attended; or don’t count against the attendance threshold.
You can soften the blow in several ways. First, have a meeting with your stakeholder physicians. Let them know that the world has shifted, and now everybody must demonstrate commitment to quality just as they’ve had to show commitment to patient care in the past. Hospitals are on the hook as much as individual doctors, and everybody needs to pull in the same direction. Point out that The Joint Commission wants to see attendance at these meetings measured in Ongoing Practice Performance Evaluations (OPPE). Set a reasonable goal for attendance: 50-60% is reasonable and can be achieved (interesting, The Joint Commission has not provided their definition of reasonable, so Quality Directors have some latitude on this currently). Also point out that more formal quality review processes will lead to real improvements in practice, and offers an opportunity to change things in the lab that impair their ability to optimize practice. Remind them that the only way they can be engaged in such changes is to be present, and these quality meetings are the chosen venue for discussion. Engage them in the conferencing process by getting a commitment to present (or arrange a speaker) and organizing a calendar. If the doctors around the table are competitors, go through the plans to assure that all quality reviews are fair (see Question 1). Discuss which hospital administrator should serve as adjudicator/mediator, if this is planned, to intercept concerns of bias by this key person.
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Do the new quality conferences replace the Peer Review Committee?
Yes. Peer review has, at its core, the principle that no one is able to judge the performance of a physician except another physician. While this is a defensible argument, quality experts are concerned that a performance review process that is not inclusive is faulted, noting that important information pertaining to performance may be available only from non-physician health care workers. Historically, Peer Review Committees have been made up of physicians only. The potential danger of such a structure, and the insular nature of physician evaluation that can result, is explored in Blind Eye, a riveting book by Pulitzer-prize winning author James T. Stewart. In this book, the notorious career of Dr Michael Swango is chronicled. The book describes how failures in physician-controlled quality supervision and communication facilitated a psychopathic physician who murdered dozens of patients across the USA and even outside America.
To assure that reviews are comprehensive, it’s critical that everybody participates. Moving away from the title “Peer Review Committee” helps with message that everyone is empowered to contribute to quality.
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How can material presented in Morbidity and Mortality Conference or other quality conferences be protected from legal discovery?
Recognizing that doctors and hospital administrators are nervous about saying or writing something that can come back to hurt them, healthcare law provides for secure internal discussions about problems of quality. Materials that are exclusively related to the internal review of a complication or other problem and are not authored by the physician in question are immune from subpoena. Anything written in the medical chart, even if it reflects discussions or plans drawn after review, is discoverable. Anything the responsible physician writes anywhere is also potentially discoverable, since it may be argued to be an extension of his record of care for the patient involved. If a case is presented in a non-quality review conference (say, a fellow’s conference because it’s an “interesting case”) materials may also be discoverable: the most important way to avoid having such materials discovered is to remove the physician in question from the process. If the physician in question presents the case, his oral presentation may be construed as an extension of his patient care. If his case is discussed without his supervision, the findings and observations will likely be considered conjecture and not admissible as evidence in a trial.
Doctors from academic centers who participate in educational conferences must be very cautious about showing complicated cases, which have obvious educational value, whenever there is the possibility of litigation. Currently, such materials are discoverable (they’re in the public domain once presented).
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Do guidelines exist for physicians in the cath lab similar to guidelines from AORN for nurses?
The Accreditation for Cardiovascular Excellence (ACE) at www.cvexcel.org, is an independent organization founded by SCAI and ACC provides guidelines for cath lab accreditation and peer-review services. The notion of quality assurance and improvement isn’t new, but the strong emphasis on quality is a relatively recent phenomenon. Past practice guidelines published by the Society for Angiography and Intervention, the American College of Cardiology, the American Heart Association and others have addressed quality metrics, but these guidelines were generally more focused on technical and clinical aspects of patient care. Guidelines focused on quality have been lacking. Thought leaders are currently building on prior art to develop a definitive guideline structure for cath lab quality. One of the important SCAI committees, the Quality Improvement Committee, is currently leading the charge, and publication of recommended guidelines is expected this year. Of course, such guidelines are fluid: everything changes, and change may come quickly, so guidelines require constant updating.
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How can a system of anonymous feedback on physician performance be developed?
This question is important because it reflects a mindset that must be changed for genuine quality improvement to take place. The historical reality has been this: nurses and other allied providers have been reluctant to speak about a problem or potential problem because they were intimidated by physicians. The day for that has ended. This doesn’t mean that nurses and doctors are equivalent in every regard (this is not true nor an appropriate system goal), but it does mean that non-physicians are empowered to speak up whenever there is a perception of threat to the quality of patient care, without concern over retribution. Not just nurses, but technicians, assistants, patient advocates, family members, janitors – everybody. Process improvement begins with data input, meaning inclusive input about quality from everyone involved in the care of the patient. This philosophy about information input is carried through the process of quality and performance review (the importance of an inclusive review process is discussed in Question 3). This means that anonymous reporting of problems should be discouraged (rare exceptions may apply). Rather, the nature and philosophy of the practice must be refreshed: the mindset of “the doctor knows what he’s doing” needs to be replaced by “the doctor needs to know what I saw”. With a refreshed attitude, combined with open and non-judgmental communication, the goals can be achieved.
How do you get there? First and foremost, a philosophical shift of this magnitude requires strong leadership. The physician leader must communicate the importance of this new approach to improvements in quality of care, and must be seen as the principle advocate and campaigner for quality (i.e., a Quality Champion). Next, the physician leader must develop a good working relationship with cath lab nursing leadership. This is a place where frictions have historically existed: doctors believed their judgment about patient care was unassailable, while nurses believed they understood things at a grassroots level better than doctors. In order for a comprehensive, inclusive quality improvement process to work, both the physician leader and the nurse leader must abandon outdated notions of supremacy and work toward a common goal. The two leaders must then foster an environment that values open communication in the lab. Nurses may need occasional reminders that communicating concerns in a non-judgmental fashion is essential, and doctors will surely need reminding that responses to concerns cannot in any way demean or devalue the reporter (use of healthy communication methods can be used as a component of Ongoing Physician Performance Evaluations). Observations and suggestions for improvement should be used, regardless of the source, in the appropriate quality conferences. Change won’t come immediately, but it will come. Using an anonymous reporting system threatens to undermine the process by inflaming old tensions between members of the team.
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Should everyone working in the cath lab environment – nurses, technicians, etc. – all attend Morbidity and Mortality Conference and other quality conferences?
YES! This is very important in fostering a collegial attitude toward quality in the cath lab. Inclusion of nurses and technicians in the conferences that review cases assures they get feedback on the value of their input – key to transforming the culture of the cath lab away from one of insular physician performance and review toward a culture of team alignment for quality improvement. The Joint Commission indicates it wants at least the Morbidity and Mortality Conference to demonstrate a comprehensive, inclusive approach to event reviews, which cannot take place without the input from allied health workers. This team-approach mindset can be best developed by involving everyone at all quality conferences, not just Morbidity and Mortality. And since some conferences such as cath conference or angiographic review can have a more casual, less structured format, they provide a great opportunity for team-building.
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Can’t vendors bring in food for conferences?
Sorry, but the practice of vendor-provided food needs to end. While it seems offensive to claim that your choice of stent or use of a particular catheter could be influenced by something as trivial as who put out doughnuts at Cath Conference, two dangers exist with vendor sponsorship of meetings: (1) Vendors see these food-oriented moments as opportunities to bond with doctors and allied health providers, hoping that personal friendship will influence product use decisions. While you may feel immune to such influence, studies confirm that this strategy works, and the vendors know it. (2) The perception of bias can be as problematic for you and your hospital as actual conflict of interest. Having someone talk about the utility of some cath lab device while the vendor for such a product has fed everyone and is standing in the back of the room may not influence discussion, but the perception that such bias is possible cannot be overcome.
You may have outside sponsors (vendors) contribute to a “no strings attached” conference or educational fund. Vendors typically have a process for providing unrestricted funds for support of educational activities. Apply for an unrestricted grant from several companies and place those funds into a holding account to be used in support of meetings. The application process is usually straightforward and is often done on-line.
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How does Morbidity and Mortality Conference compare to Continuous Quality Improvement Committee activities in terms of attendance, openness, and what is covered in the meeting?
These two conferences have some common features but are distinct. Morbidity and Mortality is held to perform a comprehensive review of problematic and complicated cases. For the most part, these will be cases involving patients who had some sort of untoward event: a death, a major complication, or an unusual complication that warrants review. The process cannot be comprehensive without input from all members of the cath lab team, so everyone is invited. Also, the process of quality improvement cannot succeed without open communication. The focus and format must be non-punitive: the goal is not to punish the operator, or to determine if serious wrongdoing was involved. Rather, the goal is to identify the root of the problem and brainstorm over how to avoid such complications in the future. Results of Morbidity and Mortality Conference are used by the Cath Lab Director (or Quality Director) in completing Ongoing Physician Performance Evaluations (OPPEs), and patterns of combinations identified through Morbidity and Mortality Conference may trigger a Focused physician Performance Evaluation (FPPE), but these are not the primary purpose of Morbidity and Mortality Conference.
Continuous Quality Improvement Processes are not focused on specific patient adverse events, although they may be triggered by specific events. This committee should consist of individuals who agree to contribute time to this committee’s activities, and should have physician and non-physician members (generally, the Quality Director and the equivalent nursing leader should participate). The committee should identify areas for improvement, assess factors contributing to the problem, agree on an action plan, then monitor results and discuss them.
For example, a patient with a complex lesion requiring a long, complicated intervention receives 500cc of contrast and develops contrast-induced nephropathy. This case, which would be reviewed in Morbidity and Mortality Conference, might trigger a decision to launch a Continuous Quality Improvement project involving improved monitoring of contrast use during long cases, a requirement that a second interventionalist be consulted to discuss whether the case should be terminated when a certain contrast volume has been exceeded, and a protocol to administer additional intravenous fluids after a certain contrast volume has been administered. The effect of these changes would be monitored by the committee, which would report their observations to the divisional Process Improvement Coordinating Group (or similar) meeting to decide if the new plan is working, should be changed, or should be abandoned. Continuous Quality Improvement Committees should be responsible for monitoring changes in best-care guidelines and recommendations from national leaders, and to recommend practice changes accordingly.
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