Why do we talk so much and so often about quality?It’s simple. We want the best for our patients. We want good care from top-rated physicians doing their work in top-rated facilities, with the most experienced and skilled cath lab staff, and with the best outcomes possible. I want my stenting performed in the best place and by the best physician, and likely, so do you. But how do we know what is the best place or even an acceptable place (or physician)? We have all read the papers about unnecessary procedures, including stents, performed in some places that were possibly not the best. Differences in “quality” are the top of the list of complaints about medical care. Last year, Richard J. Merschen, MS, RT(R)(CV), Pennsylvania Hospital and Margaret Coburn, RT(R), Jefferson College of Health Professions, Philadelphia, Pennsylvania published a detailed paper in CLD April 2010, “Continuous Quality Improvement in the Cardiac Cath Lab,” (http://tinyurl.com/MerschenCQI) spelling out the methods, goals and approaches to putting CQI to work in your lab. I highly recommend this article to those of you who are interested in this topic. The reason I bring this up again, nearly a year later, is that the healthcare reform work continues to emphasize the importance of CQI, and that this last year has had terrible press related to interventional cardiologists being unsupervised in the performance of unnecessary stenting. This issue has been in the press for the last 12 months, often bringing the question of quality behavior to the forefront of many of our lunch table conversations. I am a member of the country’s foremost interventional society, the Society for Cardiovascular Angiography and Interventions (SCAI), and we care deeply about percutaneous coronary intervention (PCI) quality. In March 2011, the SCAI published recommendations for assessing and improving the quality of PCI programs across the country.1 These recommendations are the first to offer guidance to cath labs for the building and maintaining of core measures for quality and assessment of a PCI program. This document is the latest tool for interventional cardiologists and their lab to use in their process of continual patient care improvement. Nonetheless, many who read about CQI continue to have questions when talking about ‘quality’ in medical care. What is ‘quality’ in the PCI setting? What does it mean to the doctor, nurse, patient, and institution? How does one measure quality? How does a lab start a ‘quality’ assurance program?
Why should we care about having a quality assurance program?In an era of health reform, where healthcare reimbursement systems may soon act on a “pay-for-performance” model, pre-defined measures of quality will determine your program’s survival (financially, at least), and its need for remediation or new PCI programs. These long-term goals also coincide with the short term, and probably more important, goal of insuring that your lab is performing procedures safely and with minimal avoidable patient problems. In the 2005 SCAI/American Heart Association/American College of Cardiology (ACC) PCI guidelines, it was required that all PCI facilities institute an evaluation process of performance through a continuous quality improvement (CQI) program. Most recently, the SCAI and ACC have also established a catheterization laboratory accreditation program, called Accreditation for Cardiovascular Excellence (ACE). ACE is designed to standardize and track quality measures in PCI programs.
What is PCI program quality?I believe quality in PCI is the delivery of care to the patients that provides the best outcomes with the lowest adverse events. Knowing whether or not you have a high- or low-quality program requires the tools to measure and report meaningful events and outcomes. The SCAI statement1 reports an established set of core quality measures and assessments that can be measured and reviewed for institutions with CQI programs. Dr. Lloyd W. Klein, professor of Medicine at Rush Medical College, chairman with the writing group,1 was able to delineate the specific components of a quality improvement program. I agree fully with a recent statement by Dr. Klein that “It is our responsibility as the physicians who perform interventions to actively participate in developing the tools to measure and report quality outcomes, and to ensure our patients always receive the highest quality care.”
How does a lab establish a CQI program?To start this discussion, based on the recommendations over several years, every PCI program should agree that a CQI program is needed and will be supported by hospital resources. The first step is the convening of a Cardiac Catheterization Laboratory (cath lab) CQI Committee dedicated specifically to quality performance. The CQI Committee should be led by an experienced and respected interventional cardiologist. This committee’s task is to measure and assess quality based on three basic principles:
- The structure of the (cath lab and support) systems;
- The processes involved for improving results, and;
- The outcomes achieved.
- Focus on quality of care. A group of quality indicators should be established by the CQI committee based on suggested guidelines, accreditation bodies, and local practice requirements that closely align with this focus.
- Compare quality measures to benchmarks from recent medical literature. Participation in regional or national databases is strongly encouraged. Without comparisons like this, no one inside or outside your cath lab knows where you stand.
- Form the protocol for PCI review. The CQI Committee will be guided by the protocol and all those undergoing review will have knowledge of how the review process works. While the protocol will be public knowledge, the process should be confidential to promote confidence in the goals of ongoing physician and staff education to learn about better ways for better patient care.
- Perform individual practitioner peer-review assessments. Each practitioner will have periodic assessments, including random case review, to evaluate their clinical proficiency and outcomes. Practitioners’ outcomes should also be compared against peers, and national standards and benchmark databases. The primary goal should be to identify areas which will improve outcomes within the spectrum of care. It is not intended to be punitive. Disciplinary actions are not part of this committees’ charge.
What can we do while the formal process is being established or running its course?I like what Mr. Merschen and Ms. Coburn said in their review of CQI. Several major themes were presented. These include:
- Adopt a patient-centered attitude. Customer service means treating all patients as you would expect your family member to be treated. The results will be spectacular, with great feedback.
- Encourage and support education. Knowledge is power, power to change and improve. Go to a CME/CEU meeting, bring the lessons about new and better ways home, and share them with your colleagues and administration.
- Lastly, get involved in the process. To me, this means using your talents to enhance performance and patient outcomes. Cath lab members should volunteer to serve on patient safety committees, assist in inventory management, staff and student development, clinical precepting, and advanced technology applications. In my own lab, one dedicated radiology technologist was assigned to assist, then take over, inventory management. This person found that the existing system was not efficient and revamped our inventory control, saving the hospital more than $250,000 over the last 2 quarters.
- Klein LW, Uretsky BF, Chambers C, et al. Quality Assessment and Improvement in Interventional Cardiology: A Position Statement of the Society of Cardiovascular Angiography and Interventions, Part 1: Standards for Quality Assessment and Improvement in Interventional Cardiology. Catheter Cardiovasc Interv 2011 Mar 2. doi: 10.1002/ccd.22982. [Epub ahead of print].
- Merschen RJ, Coburn M. Continuous Quality Improvement in the Cardiac Cath Lab. Cath Lab Digest 2010;18(4):20-22.