CCI: How to implement quality improvement in the cath lab
While PCI improves the quality of life and survival in certain clinical settings, these benefits are counterbalanced by the procedural risks. To encourage quality patient care, each PCI program must evaluate its performance through a meaningful continuous quality improvment (CQI) process. To help in this process, the Society for Cardiovascular Angiography and Interventions (SCAI) has published a position paper on implementing a CQI program, which appeared online March 2 in Catheterization and Cardiovascular Interventions.

The primary emphasis in CQI is on evaluating the overall program structure, processes and outcomes of care; however, specific operator performance assessed by peer review is highly desirable, according to the position paper.

The writing committee, led by Lloyd W. Klein, MD, from Rush Medical College in Chicago, said that interventional cardiologists are best suited to perform the primary role in evaluating PCI quality and guiding a program focused on objective measures.

"The process must not be payor- or hospital administration-directed, as these stakeholders may have conflicting goals," the authors wrote.

The document, however, emphasized that reimbursement in the future could be tied to quality performance, "by which larger payments would be provided to institutions and cardiologists with higher quality measures."

But the writing committee asked, "what is quality?" and "who decides?" To answer these questions, physicians must participate in the development of tools that measure and report quality outcomes, "otherwise, control over the process will be lost to those who do not possess an in-depth comprehension of interventional practice."

Not only should interventional cardiologists take part in the CQI process, but referring physicians, allied staff, hospital administration and patients also should participate.

The goal of any CQI program is to evaluate:
  • The structure of the system;
  • The processes (actions and policies) performed to further improve the results; and
  • The outcomes achieved.

Quality improvement must include an ongoing, peer review assessment of the clinical proficiency of each operator including "random case review, realistic identification of programmatic and individual operator strengths and weaknesses, and comparison of individual and aggregate outcomes against national standards and benchmark databases."

The authors noted that a single clinical variable such as operator volume by which to measure quality is "weak and inconsistent."

In the paper, SCAI urged that only validated methods be used to measure quality. "Advertising and testimonials are not measures of quality. Hospital and practitioner ranking systems and self-proclaimed 'centers of excellence' are not reliable quality indicators. Only an objective, physician-led process that includes appropriate evaluation and corrective action plans and is organized to assure a fair and impartial review of performance, provides a reasonable level of assurance that quality is being accurately assessed and promoted."

The five elements in the SCAI blueprint for a CQI program include:
  • Identification of quality indicators;
  • Systematic data collection using standard definitions;
  • Analysis of the data with benchmarking to determine areas that require improvement;
  • Development of an implementation plan to correct deficiencies; and
  • Systematic repeat data collection to determine the effect of the corrective action.

Examples of quality indicators include door-to-balloon time in acute MI, appropriate administration of dual-antiplatelet therapy, renal protection measures, lipid management and systems-based issues aimed at reducing bleeding complications and hospital readmission.

These data must be routinely measured and analyzed and SCAI recommended a dedicated database be used for this purpose.

Finally, the group noted that benchmarking against national standards is a "valuable means to understand high variances in low incidence adverse events" and can help "avoid criticisms related to self-reported data."

SCAI suggested the ACC-NCDR CathPCI Registry version 4, as well as in other recognized regional registries, as being effective benchmarking tools.