Great Lakes VSG Bylaws
I. Mission Statement
The Great Lakes Vascular Study Group (GLVSG) is a voluntary, cooperative group of clinicians, hospital administrators, and research personnel organized to improve the care of patients with vascular disease. By collecting and exchanging information, the GLVSG strives to continuously improve the quality, safety, effectiveness and cost of vascular healthcare.
Hospitals, or physician groups that participate in the Society for Vascular Patient Safety Organization (SVS PSO) are eligible for membership in the GLVSG if they are located within the state of Ohio or surrounding areas. Any new contracting entity in this geographic area who contractually elects to join GLVSG is automatically a welcome member. Hospital or physician groups or physicians contracted with the SVS PSO that participate in GLVSG are termed “Members.” Clinicians, hospital administrators, data managers and research personnel who participate in the GLVSG are termed “Participants.” They are required to follow the policies and procedures established by the GLVSG (see Section VII). If hospitals act as the contracting entity with the GLVSG (see III.), any physicians in that hospital who perform vascular procedures and submits cases to the VQI may participate in the GLVSG.
The GLVSG is an unincorporated association of Members that contract with the Society for Vascular Surgery® Patient Safety Organization (SVS PSO). SVS PSO is a Patient Safety Organization, as defined by The Patient Safety and Quality Improvement Act of 2005 (PSQIA), implemented to protect the confidentiality of all data analyses and resulting patient safety work product. GLVSG regional activities, including, semiannual meetings, administrative activity and regional data analyses, are funded by GLVSG Members through either an annual fee established by the GLVSG Executive Committee, Industry Grants, member hospitals, or other funding sources. If the GLVSG votes to fund through annual member fee, each GLVSG Member must contract with the agreed upon fiduciary agent for GLVSG to receive these payments. All industry grants should be processed through the Society for Vascular Surgery, as a non-for-profit entity, with legal standing.
IV. Committees and Staff
1) Executive Committee (EC):
The GLVSG Executive Committee (EC) consists of one representative appointed by each GLVSG Member, as well as a Medical Director, all of whom are voting members. The EC manages and conducts the business of the GLVSG and makes all decisions on behalf of the GLVSG, including oversight of budgets, contracts, publications, and relationships with outside parties, requests for membership, and the general direction of the association. The EC oversees the interaction of GLVSG with the FIDUCIARY AGENT, including costs and contractual details for GLVSG Member participation. The EC may designate other committees as necessary to conduct the business of Great Lakes VSG.
The EC may meet in person, or by conference call or email. Meetings may be called by the Medical Director, or at the request of any other two members of the EC. A quorum of the EC consists of representatives of at least fifty percent of the GLVSG Members, which is necessary to conduct business. A majority vote of the members present at a meeting at which a quorum exists is required to pass resolutions. In the event that an EC member cannot attend a meeting, the GLVSG Member may designate an alternate, who shall have full voting rights. Minutes of the EC meetings are distributed electronically or via the GLVSG website to all Members and Participants of the GLVSG.
2) Arterial/Venous Quality Committees (QC):
The GLVSG Quality Committees (QC’s) consists of GLVSG Participants, including a Chair, appointed by the Medical Director with approval of the EC. The term of membership and number of members is determined by the EC. The mission of the QC’s is to oversee quality improvement efforts in the GLVSG. This includes the development of specific quality improvement projects for approval by the EC; organizing quality presentations at the GLVSG semi-annual meetings; developing practice guidelines, care plans, and other clinical aids; revising data collection forms and reports; reviewing regional data to identify areas for quality improvement. The chairs of the Arterial and Venous GLVSG will represent GLVSG on each SVS PSO Quality Committee.
3) Research Advisory Committee (RAC):
The Research Advisory Committee (RAC) consists of GLVSG Participants, including a Chair, appointed by the Medical Director with approval of the EC. Members of the RAC will have interest and expertise in the design, conduct, interpretation, and presentation of analytic projects involving data collected by the GLVSG. The term of membership and number of members is determined by the EC. The mission of the RAC is to facilitate the conduct of quality improvement research by GLVSG Participants. The RAC will review research proposals from GLVSG Participants that request Great Lakes VSG non-identifiable regional datasets that are derived from the SVS PSO. The RAC will work with researchers to ensure that proposed research projects are novel, central to the GLVSG mission, have an appropriate analytic plan, are correctly interpreted, and are properly presented and published. At least one RAC member will serve as an author on every research product generated by GLVSG Participants, and it will be the responsibility of the RAC member(s) to ensure that the researchers act appropriately within the RAC’s policies and procedures. The RAC will make recommendations to the EC as to whether each research project should be approved. The chair of the regional RAC will represent GLVSG on the SVS PSO National RAC.
a) The Medical Director is a vascular surgeon selected by a majority vote of the EC to a three year renewable term. The Medical Director chairs the EC, prepares the agenda for GLVSG meetings, prepares an annual budget and is responsible for the overall operations of the GLVSG between meetings of the EC. The Medical Director will represent GLVSG on the SVS PSO National Governing Council unless the EC decides to elect someone else in the region.
b) Staff Members may be hired by the EC to meet organizational and analytical needs of GLVSG, or such services may be contracted from an outside entity. Staff members are selected by the Medical Director with approval by the EC. Their percentage effort and associated salary are set by the EC, consistent with the annual budget. GLVSG Staff may include but are not restricted to statisticians, data analysts or administrative assistants.
V. Shared Data Ownership
Each GLVSG Member owns the clinical data that it submits to the SVS PSO, and is entitled to specify and control the use of its data as set forth in its contract with the SVS PSO. Thus, any GLVSG use of non-identifiable data submitted by Members for purposes other than the quality improvement functions performed by the GLVSG, such as health services research, shall require the prior consent of the Member, requested and recorded by the SVS PSO for each instance.
The following principles guide the function of the GLVSG and must be adhered to by all Members and Participants:
- All activities of the GLVSG must be consistent with the Mission Statement. All data reports that compare physicians or hospitals must be anonymous, as specified in the PSQIA. All Participants in the GLVSG agree to follow the rules of the PSQIA and keep such information strictly confidential.
- Each physician Participant must submit data for all consecutive procedures for the procedure types they elect to enter through the SVS PSO, and must agree to submit billing data as specified by the SVS PSO on a periodic basis to allow an audit to ensure accurate and complete data entry.
- Each hospital Member agrees to submit billing data as specified by the SVS PSO on a periodic basis to allow an audit to ensure accurate and complete data entry.
- Each Member and Participant must submit complete data forms using a web-based system approved by the SVS PSO, including follow-up data at one year, or other time points established by SVS PSO.
- Each Member and Participant agrees that comparative data can never be used for competitive marketing. Thus, benchmarking reports that compare hospitals or physicians can never be published. , consistent with the PSQIA
- Each Member and Participant agrees to follow all provisions of the PSQIA to prevent the disclosure of any patient identifiable information, as well as any hospital or physician identifiable information. Further, each Member and Participant agrees to follow all regulations contained within the Hospital Insurance Portability and Accountability Act (HIPAA).
- Failure to adhere to these policies may result in loss of membership in GLVSG for a hospital or physician group, if so determined by a majority vote of the EC.
Proposals for health services research projects using shared, non-identifiable GLVSG regional data may be made by any GLVSG Participant and shall be considered by the EC after review by the RAC. If approved by the EC such projects may proceed. All GLVSG Members conducting such research agree to abide by all GLVSG confidentiality rules, all HIPAA regulations, and all PSQIA regulations that are relevant to protecting the privacy of both patients and Members, none of whom shall be identified in any publication. All resulting publications and presentations shall be authored by the specific participating researchers from the GLVSG and carry the author byline “on behalf of GLVSG.” The Principal Investigator of, and each Participant in, such research projects must sign a statement that attests to these agreements.
Bylaws may be amended by a vote of two-thirds of the full membership of the EC provided that such amendments are circulated electronically at least 30 days prior to their consideration.