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Quality Improvement Model

VCSQI focuses on high-risk patients and high-cost procedures to uncover performance variations in operative/procedural 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.



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Virginia Chapter of the American College of Cardiology

3445 Seminole Trail, Suite 253
Charlottesville, VA 22911
Phone: 877-793-8171
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