Systems Theory and the Society for Vascular Surgery Patient Safety Organization

1. Systems Theory and the Society for Vascular Surgery Patient Safety Organization Vascular Quality Initiative Cheryl Jackson, DNP, MS, RN, CNOR, CPHQ

2. Systems Theory and the SVS PSO VQI • History of Systems Theory • Application to VQI

3. Systems Theory and the SVS PSO VQI (Health Care Professionals, family, Data managers/abstractors, Health Care Centers, IT Regional Groups Society for Vascular Surgery Patient Safety Organization Vascular Quality Initiative

4. Systems Theory at the Center Level • Frontline care providers • Health Care Providers • Family • Data Managers/Abstractors • Health Care Centers • IT

5. Center Level – Iowa Heart Center • Validation Audit – 2017 (for 2015 cases) • QI tools used • FMEA • PDCA

6. Center Level – Iowa Heart Center • Emergencies • Add-on cases • Bedside procedures • Hospital consults

7. Center Level – Iowa Heart Center The Failure Mode and Effects Analysis • A structured approach to discover potential failures that may exist within a design or process • Developed in the 1950s, FMEA was one of the earliest structured reliability improvement methods. Still a highly effective method of lowering the possibility of failure. • Failure Modes are the ways a process can fail • Effects are the ways these failures lead to poor outcomes • Effects Analysis refers to studying the consequences of those failures or outcomes

8. Center Level – Iowa Heart Center • Define the FMEA topic – why are we missing billing? • Assemble the team – staff and key stakeholders for all aspects of the process. Multi-disciplinary teams help ensure the results are credible and comprehensive. • Describe the process and who is responsible for what – clearly identify which steps are within each team members scope. • Conduct the analysis • Identify the Failure Modes for each process step. • Score each Failure Mode. Assign a risk score of 1, 2, or 3 points for severity, frequency of occurrence, and probability that the failure would be detected and corrected before harm (lack of billing) could occur. • severity – how bad is the effect? • frequency – how often does it happen? • detection – when it happens, how hard is it to know?

9. Center Level – Iowa Heart Center • Calculate a Risk Priority Number (RPN) for each failure mode by multiplying the assigned value for severity, occurrence, and detection. • RPN = severity x occurrence x detection • This helps to develop an Action Plan based on risk • Prioritize the Action Plan process steps using the highest RPN • Note: a word of caution when using RPN values to assess risk – RPNs have no value or meaning in themselves. Although it is true that larger RPN values normally indicate more critical failure modes, this is not always the case. Severity is given the most weight when assessing risk. http://www.fmea-fmeca.com/fmea-rpn.html

10. Center Level – Iowa Heart Center • Failure Mode Effects Analysis (FMEA)

11. Center Level – Iowa Heart Center Missed Opportunities • RPN 18 - Capture office or bedside debridement procedures at a higher percentage • Discussed with coding / billing department what documentation was needed to correctly code for a debridement procedure • Surgeons and office/hospital staff were unsure what made a debridement “billable” • RPN 6 - Missed consults • Inconsistencies among surgeons • A call from the OR for an opinion from another surgeon/service • A call from the cath lab for an opinion on further vascular treatment or to examine and assess a groin site • Did we just have a billable consults? Our surgeons wanted guidance.

12. Center Level – Iowa Heart Center • Plan – Do – Check/Study – Act

13. Center Level – Iowa Heart Center Results • IHC identified the billing “failure” in Jan. 2018 from their VQI audit results and the team began their first PDCA improvement process cycle the end of Feb. • In a retrospective review of Jan. - found 6 cases missed • Feb – 2 cases • March – 2 cases • April – 0 cases • May – 3 cases • June – 3 cases • July – 0 cases • August – 2 cases again and 2 cases under the wrong surgeon name • Without the Quality Improvement project - 18 surgery cases would have been missed for billing in 2018!!!

14. Center Level – Iowa Heart Center ROI • All 18 surgery patients missed were billed • Two cases of wrong surgeon name were corrected • Identified over 20 cases of bedside procedures that were referred to the billing/coding department for review • Identified 12 cases for billable hospital consults • As a team - Continuing to improve process! • Still room for improvement! SO… • The PDCA cycle will continue

15. Center Level – Iowa Heart Center This is Lloyd Bik! He can be sweet as sugar when he agrees to do something and stubborn as an A** when he doesn’t. At any point in an improvement process you may meet up with one or more “stubborn Lloyds” - it will be your challenge to keep the team on track, encourage new ideas and solutions, celebrate progress, large or small - because success in the end will be as sweet as sugar!!

16. Systems Theory at the Regional Level

17. Systems Theory at the Regional Level Julie Beckstrom, MSN, RN, CCRC University of Utah #Hashtag

18. What is a #hashtag? • A hashtag is the pound sign: # • Used to organize data in a standardized way • Complies with the Patient Safety Act • Insert the pound sign directly in front of the word or phrase you want to be a hashtag #Hashtag #anythingcanbeahashtag #eventhis @UofUVascular

19. #hashtag data entry @UofUVascular

20. VQI Rocky Mountain RegionRenal Protection Project • Initiated April 2015 by Dr. Benjamin Brooke at the University of Utah • University of Utah – Salt Lake City, Utah • St. Luke’s – Boise, Idaho • St. Vincent – Billings, Montana • Carondelet – Tucson, Arizona • Penrose St. Francis – Colorado Springs, CO • St. Pat’s – Missoula, Montana • QI effort to standardize indication and use of CIN preventive measures • Targeting pts undergoing EVAR being captured in VQI @UofUVascular

21. Renal Protection #hashtags @UofUVascular

22. Frailty4Site • Initiated May 2018 by Dr. Larry Kraiss at the University of Utah • University of Utah – Salt Lake City • Emory University – Atlanta • University of Nebraska - Omaha • Dartmouth-Hitchcock – Lebanon, NH • Compare frailty assessment tools and learn which best predict outcomes of surgery • Targeting pts undergoing any major procedure being captured in VQI @UofUVascular

23. Frailty4Site #hashtags @UofUVascular

24. Process to request #hashtag data • Request #hashtag data from Nancy Heatley, nheatley@svspso.org • M2S will send a file with the #hashtag data, blinded by center ID • At least 3 centers need to have #hashtag data with at least 10 cases in order to release the data Julie.Beckstrom@hsc.utah.edu @UofUVascular

25. Systems Theory at the National Level Number of Participating Centers Location of VQI Participating Centers 571 VQICenters 570 centers in North America 1 center in Singapore (As of 06/01/2019)

26. Systems Theory at the National Level National QI Initiatives • D/C Meds – Anti-coagulation and Statins • LTFU EVAR Imaging

27. Systems Theory at the National Level

28. Systems Theory at the National Level Tools • Charters • Focused phone calls • VQI Website • Forums • Sample charters • Dissemination • Internal and external • Webinars • Poster and podium presentations

29. LTFU – Dates to Remember • Fall regional reports: • Procedure date cut off May 31st • Data entry cut off June 30th • The 2019 Fall report for LTFU will cover July 1, 2016 to June 30, 2017. Entered into VQI as of June 30, 2019. • Spring regional reports: • Procedure date cut off December 31st • Data entry cut off January 31st • The 2020 Spring report for LTFU will cover January 1 – December 31, 2017 and entered as of January 31, 2019. Remember – It’s never too late to enter LTFU – even for cases outside of 21 months.

30. LTFU Table

31. Systems Theory at the National Level Participation Awards 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

32. Systems Theory at the National Level Participation Awards Maximum number of points for any category is 6 points Total points = 4 x LTFU score + 3 x Attendance score + 2 x QI project score + 1 x Registry score

33. Systems Theory at the National Level Participation Awards QI and the Participation Award • LTFU • <70% = 0 points • >=70% = 2 • >=80% = 4 • >=90% = 6 • Regional Meeting attendance • Each regional meeting will be scored on a 0-3 point scale, the same way we are doing it now: • 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 MD attends, 2 points • If site has <3 MDs and all MDs attend, 3 points • Extra point for support staff attending with an MD (but not if it pushes total for that meeting over 3 points). • If no MD attends, 0 points, regardless of support staff attendance If total score for both meetings is < 6 points, the center can receive an additional point if any non-physician staff member attends VQI@VAM

34. Systems Theory at the National Level Participation Awards QI and the Participation Award • QI Project • 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/Research Project (presentation or poster) at a Regional VQI or Regional Society Meeting • Presenting a QI/Research Project (presentation or poster) at the National VQI or Vascular Annual Meeting • Publish in a Peer Reviewed Journal • Improvement of rates on National QI Initiatives, or maintaining excellent performance rates • 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

35. Systems Theory at the National Level Participation Awards • New Participation Committee • Thanks to Dr. Alex Shepard – outgoing Chair (Henry Ford Hospital) • Welcome to Dr. Daniel Bertges - incoming Chair (University of Vermont Medical Center) • Thanks to all who answered the call to work on this committee • 1st meeting on Thursday • 2nd workgroup with non-physician members

36. Systems Theory and the SVS PSO VQI Thank You