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• The Role of Data in Quality Improvement
• Types of Measures in Quality Improvement
• Sources of Data in Quality Improvement
• Data Visualization

The Role of Data in Quality Improvement

The modern quality improvement practices have initially been influenced by the continuous improvement in the automotive industry. These practices have been adopted in the healthcare system to deliver safe, consistent, and effective care to patients. Qualitative and quantitative data can be used to answer questions, monitor changes, and inform decision-making within a healthcare system (Figure 1). Use of data in quality improvement differ from traditional research with the expectation to assess results in shorter intervals and to incorporate existing evidence correlated with high-quality care into practice rather than posing new evidence.

Types of Measures in Quality Improvement 

A healthcare system is comprised of multiple factors and sources that affect outcome. Similarly, multiple data measures are required to understand the performance of a complex system and monitor quality improvement. The Donabedian model classifies measures to assess and compare the quality of healthcare systems in forms of outcome, process, structure, and balancing measures.

Sources of Data in Quality Improvement

Data used to assess healthcare quality are available from various sources including administrative data, registries, patient medical records, patient surveys and interviews, and direct observation. The selection of the data source depends on the types of measures required to evaluate and monitor quality improvement interventions and the quality of the data from various information systems.

It is important to consider the types of measures to be extracted from the data source and the quality of the data. The data may vary in accessibility, availability, accuracy, completeness, consistency and usability across various data sources. (Adapted from Vavra 2023 J Vasc Surg Vasc Insights)

Data Visualization

Image	Cause and Effect Diagram A fishbone diagram that identifies contributors to certain effects or outcomes and examines the relationship of cases to the effect and to each other
Image	Pareto Chart A Pareto chart is a bar chart composed of various factors that contribute to an overall effect arranged in the order from the largest to smallest contribution to the effect. It identifies and allows concentration of improvement on the “vital few” factors that have the largest contribution to the effect and “useful many” factors that have relatively smaller contribution to the effect.
Image	Driver Diagram A diagram that displays identified “primary or secondary drivers” or contributors and the relationship between them in relation to the overall aim of the project
Image	Run chart A graph that depicts the current performance of a process and monitors whether interventions lead to improvement

The SVS Quality Improvement Committee has assembled the resources linked below to help any vascular team successfully start a new project for improving patient outcomes. If you have questions, please email svsquality@vascularsociety.org. PDSA (Plan-Do-Study-Act) Framework for QI projects:

• What is the PDSA cycle? While there are many different frameworks for organizing a project, the PDSA cycle is one of the most commonly utilized and referenced. PDSA stands for Plan-Do-Study-Act and this method originates from industry but is easily applied to the healthcare setting.
• What are the steps of the PDSA cycle?

Image

• PLAN: 
  • Start by asking: what are we trying to improve? For example, perhaps your group notices that your surgical site infection rate after lower extremity arterial bypass has been above the regional and national mean for the past three quarters. Once you have identified an opportunity for improvement (see tips and tools), you then execute the following steps:
    1. Recruit a team: a diverse team of members who have varying areas of expertise (ex. subject matter, quality or process improvement) is helpful. Once assembled, clarify roles and responsibilities, set timelines and a meeting schedule
    2. Identify opportunities for improvement in the current process (ex. surgical site infection prevention)
       • Search the literature and interview experts to identify relevant best-evidence practices. Example: antibiotics within 30 minutes of incision time, normothermia, sterile surgical site preparation with alcohol-based preparation and appropriate hand washing are associated with decreased SSI after lower extremity arterial bypass.
       • Map out your existing process and compare the existing state to the desired state.
         • Identify major steps in the process, who is involved and whether the steps are performed consistently. The goal is to compare what we think is happening with what is actually happening. This may include direct observation or audits in addition to interviews with process owners.
         • Identify if there are missing steps or areas where there is an opportunity to improve the steps. Also, take note of any wasted or areas of inefficiency if relevant.
         • You may use a process map or swim lane map to organize the information and review with stakeholders. 
         • You can utilize a pareto chart or fishbone diagrams in this step to brainstorm any specific causes of error or problems. 
    3. Identify specific interventions that you feel will result in improvement in the process and outcome. 
       • Interventions should address the key drivers of error or problems identified in step two. A driver diagram can be used to organize this information. 
       • Tip: Focus on the low-hanging fruit. Considerations for interventions should prioritize simplicity rather than complexity such as improvements in existing processes instead of new processes. In addition, interventions that do not rely on memory are much more effective (ex. integration into an existing orderset rather than providing education and reliance on memory
       • When there are multiple possible interventions available, use your team to help prioritize a few changes as an initial start.
    4. Draft a problem statement and a SMART goal: The problem statement helps clarify the specific problem. SMART stands for specific, measurable, achievable, relevant and time-bound and a SMART goal helps clarify what level of improvement you are hoping to achieve and in what time frame. 
       • For example, the steps above reveal many patients are prepped with Betadine and antibiotics prophylaxis is frequently administered after incision. Plan - switch all skin preparation from Betadine to Chlorhexidine and add commonly used antibiotics to the PICS in the preoperative area to avoid delays in delivery to the OR.
       • Resultant example problem statement and SMART goal:  Postoperative surgical site infection is associated with increased morbidity and cost of care. Surgical site infection rates following lower extremity arterial bypass at our institution are significantly higher than the national benchmark (ex. 8% vs. 3%). We will decrease surgical site infection rates following lower extremity arterial bypass by half within 8 months by switching the type of skin preparation and ensuring antibiotic prophylaxis is administered within 30 minutes of incision.
    5. Develop a project charter that includes the problem statement, SMART goal and also the process and outcome measure you will track and use to define success. The charter will also include the roles and responsibilities you outlined for your team earlier in the planning phase. See the template project charter here. 
• DO:
  1. Implement the proposed changes. 
     • It is vital to review the process changes with the process owners to anticipate any barriers, particularly if there are process owners who are not a part of your team.
     • Have a plan for how to determine if the process changes are actually happening (ex. regular audit of skin preparation type and time of antibiotic prophylaxis prior to incision).
     • It is helpful to have a specific kick-off date and a plan to celebrate early wins (ex. public shout-out to the team members who have the best adherence to set goals or provide weekly compliance rates for team members to review).
     • Make sure stakeholders have a clear way to report any unanticipated challenges or barriers.
     • Have a plan for when and how to review the results with both your team and various stakeholders
• STUDY:
  1. Gather data that is relevant to your SMART goal and review it regularly. The timeframe will vary depending on the process and how frequently it is utilized (ex. if you only do one lower extremity bypass a week, then you may want to review monthly).
  2. Are there any unanticipated outcomes that have occurred as a result of your changes? These are often called balancing measures. For example, if your goal is to reduce the length of stay, it’s possible you may achieve this goal but at the expense of increased readmissions.
• ACT:
  1. If your interventions have resulted in the desired outcome, then this step consists of making these changes permanent and identifying a plan for monitoring over time to address any new problems
  2. In many cases, there is some improvement but not at goal or perhaps no discernable change. If you can confirm that the proposed changes in the process are happening (ex. >80% compliance), then you should return to the PLAN phase and reevaluate. Multiple PDSA cycles may be utilized for a project.

• Additional information from the Institute for Healthcare Improvement (IHI)
  • Whiteboard: The PDSA Cycle (Part 1) https://youtu.be/_-ceS9Ta820 
  • Whiteboard: The PDSA Cycle (Part 2) https://youtu.be/eYoJxjmv_QI 

Supplemental Tips and Tools for Success

• How to decide where to start improving
  • Brainstorming exercise
  • Dot matrix exercise
  • Prioritization matrix
• Data and Measurement in Quality Improvement
  • Examples of measures (Donabedian)
  • Repeat data tools with instructions (fishbone, driver, process map, run chart, pareto)
• How to get people on board
  • Stakeholder Analysis
  • Building a successful team
  • Making a case for change (Kotter's model)

Quality improvement (QI) is the process of systematically approaching and improving problems in healthcare. These initiatives are critical to enhancing care, improving patient outcomes, and lowering costs. 

The SVS Quality Improvement Committee has designed a comprehensive QI toolkit for physicians. This toolkit equips healthcare providers with the necessary resources and tools to initiate and lead quality improvement projects within their own institutions or practices. It includes free, publicly available exercises, tutorials, visuals, and that you can tailor for vascular care. 

If you have questions, please email svsquality@vascularsociety.org.

What is Quality Improvement?

Toolkit Links

• How to Get a Project Started
• Understand the Role of Data in QI
• How to Visualize Data

About

The Society for Vascular Surgery (SVS) Quality Improvement Committee has created a series of toolkits for vascular surgeons for patient-reported outcomes, or PROs. A PRO is any report of the status of a patient’s (or person’s) health condition, health behavior, or experience with healthcare that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.

There are several types of PROs, satisfaction scores and health-related quality of life (HRQOL). HRQOL is most commonly used because it is less subjective. HRQOL assesses how a disease and its treatment affect the physical, psychological and/or social aspects of life. 

The domains of quality of life used to measure PROs are:

• Symptoms 
• Pain
• Psychological symptoms (i.e. anxiety, depression)
• Effect of social activities
• Functional status

Toolkits

• PROs Toolkit: Basics of Survey Administration and Data Collection
  •  Resources regarding PROs-related survey administration and data collection.
• PROs Toolkit: Inventory of Existing PROs
  • Resources regarding the inventory of existing PROs.
• PROs Toolkit: Psychometric Properties
  • Resources regarding the psychometric properties of PROs.

Reference Library 

• Current status of patient-reported outcome measures in vascular surgery
• Supplemental Materials

If you have questions, please email svsquality@vascularsociety.org.

Call for Comments on Vascular Surgery MIPS Value Pathway

The SVS is excited to announce that the Vascular Surgery MIPS Value Pathway (MVP) has been posted for public comment with CMS.

The development of Vascular Surgery MVP is the first step in developing the specific, required quality metrics that improve vascular care

The public comment period will be from Dec. 11 - Jan. 24, 2025.

Please send your comments to PIMMSMVPSupport@gdit.com.

Read Vascular Surgery MIPS Value Pathway (MVP)

Your resources for MACRA, MIPS, QPP and more

How Medicare Quality Requirements Will Impact Reimbursement & Practical Tips To Successfully Meet Them

On Feb. 29, the SVS hosted the webinar, How Medicare Quality Requirements Will Impact Reimbursement & Practice Tips to Successfully Meet Them. 

Vascular surgeons have repeatedly acknowledged financial threats to the specialty secondary to changes in reimbursement and government policies, specifically those involving the Centers for Medicare and Medicaid Services (CMS). Vascular surgeons must be empowered to navigate current and future requirements and regulations to both ensure continued high-quality care for their patients and also to preserve their financial viability. All providers who submit claims to CMS, regardless of practice setting, are required to submit quality measures as part of the Merit-based Incentive Payment System (MIPS) Quality Payment Program (QPP) or through an Alternative Payment Model (APM). While many SVS members may not be directly involved with QPP reporting currently, there are new requirements anticipated in the near term that have direct implications for all. 

Vascular surgeons are encouraged to watch the webinar recording to fully understand these policies, and how to comply with them, to prevent reimbursement penalties with the rollout of the future CMS rules. 

Supporting documents:

• How Medicare Quality Requirements Will Impact Reimbursements (Webinar Slides)

Do you know what quality measures you report on?

Based on your performance on CMS quality measures, you could receive a negative payment on top of any scheduled CMS payment cuts. It is pivotal for physicians to know what measures are being reported on their behalf. CMS publicly makes available your performance data available annually. This information will help guide you in leveraging reporting that is reflective of the care you provide. We have created a file where you can look up your information and coordinating data definitions and instructions. If you have any questions, please contact the SVS via SVSquality@vascularsociety.org.

Access the File

Please note: when opening the file, it will be too large to open in your browser. Some browsers (Chrome, for example), will automatically download the file for you. If you are opening in another browser (Edge), please click the prompt at the top of the screen to initiate the download. 

• 2022 QPP Experience Report
• 2022 QPP Data Use Guide
• Quality Payment Program Experience Data Instructions

Additional Resources

The Medicare Access and Children’s Health Insurance Plan Reauthorization Act (MACRA) was signed into law on April 16, 2015.  MACRA is bipartisan legislation which repealed the Sustainable Growth Rate and established the Quality Payment Program (QPP).  The QPP requires that most physicians who submit claims to the Centers for Medicare and Medicaid Services (CMS) participate in one of two programs: Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Model (APM).   

Based on feedback from physicians and stakeholders led the QPP to create the following objectives:

• To improve beneficiary population health
• To improve the care received by Medicare beneficiaries
• To lower costs to the Medicare program through improvement of care and health
• To advance the use of healthcare information between allied providers and patients
• To educate, engage and empower patients as members of their care team
• To maximize QPP participation with a flexible and transparent design, and easy to use program tools
• To maximize QPP participation through education, outreach and support tailored to the needs of practices, especially those that are small, rural and in underserved areas
• To expand Alternative Payment Model participation
• To provide accurate, timely, and actionable performance data to clinicians, patients and other stakeholders
• To continuously improve QPP, based on participant feedback and collaboration

For more information, you can access the QPP here: The Quality Payment Program (cms.gov)

Announcements 

SVS Response to the MPFS CY 024 Proposed Rule

Information

CMS Resource Library A trove of background information, documents and downloads

Featured Articles

Monthly topics published in the Journal of Vascular Surgery and JVS-Venous and Lymphatic Disorders

See our acronym resource guide here.