SVS PSO Governance Policies

ARTICLE I. Name

The organization shall be known as the Society for Vascular Surgery Patient Safety Organization, hereinafter referred to as the “SVS PSO.”

ARTICLE II. Purpose

The purpose of the SVS PSO is to improve the quality, safety, effectiveness and cost of vascular healthcare by collecting and exchanging information through regional quality improvement groups.

The SVS PSO is a Patient Safety Organization, as defined by the Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41), implemented to protect the confidentiality of all data and resulting patient safety work product. The SVS PSO engages in patient safety activities focused on vascular and related therapies, including, but not limited to:
(i) efforts to improve patient safety and the quality of health care delivery;
(ii) the creation and analysis of patient safety work product (“PSWP”);
(iii) the development and dissemination of information with respect to improving patient safety, such as recommendations, protocols, or information regarding best practices;
(iv) the utilization of PSWP for the purposes of encouraging a culture of safety and of providing feedback and assistance to effectively minimize patient risk;
(v) activities related to the operation of a patient safety evaluation system (“PSES”) and to the provision of feedback to participants in a PSES;
(vi) compilation of information regarding patients undergoing certain vascular procedures, preparation of anonymous comparisons and other quality reports; and
(vii) facilitating and providing administrative services in connection with the formation of regional quality groups consisting of three or more PSO contracting entities for the purpose of regional quality improvement by aggregating submitted data on a regional level, and compiling/organizing the results.

ARTICLE III. Participation

Hospitals, physicians or other practice entities contract with the SVS PSO to participate in the quality improvement activities protected under the Patient Safety and Quality Improvement Act. The form of the contract between SVS PSO and the practice entities must be approved by the SVS PSO Governing Council, including the costs for participation. The contract must affirm the practice entities’ adherence to the SVS PSO policies and procedures. See exhibits A and B.

Regional quality groups comprised of at least three practice entities that participate in the PSO may be accredited by the SVS PSO and afforded status as an SVS PSO regional vascular quality group with representation on the Governing Council and Quality Councils. Individual physicians or practice entities not part of a regional study group may also participate. The bylaws of each accredited regional quality group must be approved by the SVS PSO Medical Director. These must contain a purpose consistent with the SVS PSO,

mechanisms for regional quality improvement including semi-annual meetings, and a review process for research using non-identifiable regional data derived from the SVS PSO, including a mechanism for each contracting entity within the regional group to approve the use of their non- identifiable data for each approved research project.

ARTICLE IV. Governing Council

The Governing Council conducts the business of the PSO and makes all decisions on behalf of the PSO, including oversight of budgets, contracts, policies and procedures, publications, relationships with outside parties, and the general direction of the organization. With the Medical Director and the Administrative Director, the Governing Council shall assure compliance with federal regulations governing PSOs.

The decisions of the Governing Council are subject to approval by the Board of Directors of the Society for Vascular Surgery (SVS) for the following: adoption of an annual budget, authorization of major changes in the purpose or operations of the SVS PSO or any other action of the Governing Council identified by the chair of the Governing Council as involving a significant legal issue. No action of the Governing Council with respect to any such matter shall be effective and binding until approval by the SVS Board of Directors has been obtained.

The Governing Council consists of four representatives, including the chair and vice-chair, appointed by the Society for Vascular Surgery, two representatives appointed by the American Venous Forum, two representatives appointed by the Society for Vascular Medicine and one representative appointed by each regional vascular quality group. One representative may be appointed by any endorsing national specialty society not represented by a regional vascular quality group, provided that the endorsing society includes members participating in the VQI. The SVS PSO Medical Director , the chairs of the PSO Quality Councils and chairs of the Research Advisory Committees shall be ex officio non-voting members of the Governing Council.

The Governing Council may meet in person, by conference call or by email. Meetings may be called by the chair, or at the request of any other two members of the Governing Council.

The duration of the term for Governing Council members is at the discretion of the organization being represented by the individual. In the event of a vacancy in the Governing Council, the remaining members of the Council may exercise the powers of the full Council until the vacancy is filled.

A quorum of the Governing Council consists of at least half the Governing Council members at the time of the vote. A majority vote of the members present at a meeting at which a quorum exists is required to pass resolutions. Minutes of the Governing Council meetings shall be distributed electronically to all Governing Council members.

ARTICLE V. Officers

The officers of the SVS PSO Governing Council shall consist of chair and vice-chair. The chair and vice chair of the Governing Council shall be appointed by the SVS Board of Directors.

The chair shall preside at all meetings of the Governing Council and shall, in general, perform all duties customarily incident to the position of president or chair and such other duties as may be prescribed from time to time. The chair shall report regularly to the SVS Board of Directors. The vice-chair shall assume the duties of the chair when the latter is not available.

ARTICLE VI. Executive Committee

An Executive Committee of the Governing Council shall exercise the authority of the Council between Governing Council meetings, except as otherwise provided by these governance policies.

Membership
The Executive Committee shall consist of the following five (7) voting members: chair, vice chair, chairs of the Arterial and Venous Quality Councils and three elected annually by the Governing Council from among Governing Council members.

The at-large members will serve for three years, with staggered terms. The election shall occur in June of each year. The three individuals with the highest number of votes will be elected.

The Medical Director and the President of the SVS PSO shall be non-voting members of the Executive Committee.

Quorum and Voting
A quorum of the Executive Committee consists of at least four of the voting members at the time of the vote. A majority vote of the members present at a meeting at which a quorum exists is required to pass resolutions. Minutes of the Executive Committee meetings shall be distributed electronically to all Governing Council members.

ARTICLE VII. Councils and Committees

The Governing Council may from time to time establish such councils and committees as it deems advisable. Such councils and committees shall consist of such number of persons, and shall have such powers, as designated by the Governing Council.

SVS PSO standing councils and committees include the SVS PSO Quality Councils and SVS PSO Research Advisory Committees.

The role of the SVS PSO Quality Councils is to improve patient safety and the quality of vascular healthcare delivery as directed by the Governing Council. This includes the creation and analysis of patient safety work product (“PSWP”); the development and dissemination of information with respect to improving patient safety, such as recommendations, protocols, or information regarding best practices; and the utilization of PSWP for the purposes of encouraging a culture of safety and of providing feedback and assistance to effectively minimize patient risk.

The Quality Councils will design and implement appropriate data collection instruments, analyze submitted data, develop risk-adjustment algorithms, and prepare benchmark reports (PSWP) for SVS PSO members. They will coordinate quality efforts of regional groups and facilitate quality research performed by regional groups.

There shall be two quality councils, one for arterial and one for venous disease.

• The Arterial Quality Council shall include members who are active PSO participants with an interest in arterial disease appointed by the Society for Vascular Surgery, including the chair, two representatives from the Society for Vascular Medicine, plus representatives from each regional vascular quality group. One representative may be appointed by any endorsing national specialty society not represented by a regional vascular quality group, provided that the endorsing society includes members participating in the VQI. The number of representatives shall be determined by the Governing Council. The SVS PSO medical director shall be an ex officio member.

• The Venous Quality Council shall include members who are active PSO participants with an interest in venous disease. Two members shall be appointed by the Society for Vascular Surgery, three members including the chair will be appointed by the American Venous Forum, two members shall be appointed by the Society for Vascular Medicine and a representative from each regional vascular quality group will be appointed by these groups. One representative may be appointed by any endorsing national specialty society not represented by a regional vascular quality group, provided that the endorsing society includes members participating in the VQI. The SVS PSO medical director shall be an ex officio member.

Research Advisory Committees
The role of the Research Advisory Committees is to review research proposals and approve PSO data releases according to the data release policies established by the Governing Council. The Research Advisory Committees also maintain a database of studies and publications derived from PSO data.
Research Advisory Committees may be established for arterial research and for venous research.

ARTICLE VIII. Staff

The SVS PSO shall engage a Medical Director to provide clinical and scientific expertise and to manage the work of the PSO. The Medical Director shall engage such additional staff for the PSO as are needed to fulfill the organizational and analytical needs of the PSO, subject to budget approval by the SVS PSO Governing Council.

The Medical Director shall be an ex officio, non-voting member of the Governing Council and the Governing Council Executive Committee and an ex officio member of the SVS PSO Arterial and Venous Quality Councils.

The Society for Vascular Surgery shall provide administrative support for the SVS PSO Governing Council and Governing Council Executive Committee.

ARTICLE IX. Indemnification

To the full extent permitted by, and in accordance with the procedure prescribed in the General Not for Profit Corporation Act of Illinois, the Society for Vascular Surgery shall indemnify any and all of the members of the Governing Council and any and all of the officers, staff, agents and representatives of the SVS PSO for certain expenses and other amounts paid in connection with legal proceedings in which any such persons become involved by reason of their serving in any such capacity for the SVS PSO.

ARTICLE X. Amendments

These governance policies may be amended by the Board of Directors of the Society for Vascular Surgery. Participating practice entities will be notified of changes in a timely manner.

 

(Updated June 2015)