Carolinas Vascular Quality Group Bylaws
l. Mission Statement
The Carolina Vascular Study Group (CVSG) 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 CVSG 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 CVSG if they are located within North and South Carolina. Any new contracting entity in this geographic area who contractually elects to join CVSG is automatically a welcome member. Hospitals or physician groups or physicians contracted with the SVS PSO that participate in CVSG are termed “Members.” Clinicians, hospital administrators, data managers and research personnel who participate in CVSG are termed “Participants.” They are required to follow the policies and procedures established by CVSG (see Section VII). If hospitals act as the contracting entity with CVSG (see III.), any physicians in that hospital who performs vascular procedures and submits cases to the VQI may participate in CVSG.
The CVSG is an unincorporated association of Members that contract with the Society for Vascular Surgery® Patient Safety Organization (SVS PSO) for quality improvement services. 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. CVSG regional activities, including semiannual meetings, administrative activity and regional data analyses, are funded by CVSG Members through either an annual fee established by the CVSG Executive Committee, Industry Grants, or member hospitals. If the CVSG votes to fund through annual member fee, each CVSG Member must contract with the agreed upon fiduciary agent for CVSG 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 CVSG Executive Committee (EC) consists of one representative appointed by each CVSG Member, as well as a Medical Director, all of whom are voting members. The EC conducts the business of the CVSG and makes all decisions on behalf of the CVSG, including oversight of budgets, contracts, publications, relationships with outside parties, requests for membership, and the general direction of the association. The EC oversees the interaction of CVSG with the FEDUCIARY AGENT, including costs and contractual details for CVSG Member participation. The EC may designate other committees as necessary to conduct the business of CVSG.
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 CVSG 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 CVSG Member may designate an alternate, who shall have full voting rights, this person does not need to be a physician. Minutes of the Executive Committee meetings are distributed electronically or via the CVSG website to all Members and Participants of the CVSG.
2) Arterial/Venous Quality Committee (QC):
The CVSG Quality Committees (QC’s) consists of CVSG 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 CVSG. This includes the development of specific quality improvement projects for approval by the EC; organizing quality presentations at the CVSG semi-annual meetings; developing practice guidelines, care plans, and other clinical aids; revising data collection forms and reports; and reviewing regional data to identify areas for quality improvement. The chairs of the Arterial and Venous CVSG will represent CVSG on the SVS PSO National Quality Committees.
3) Research Advisory Committee (RAC):
The Research Advisory Committee (RAC) consists of CVSG 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 CVSG. 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 CVSG Participants. The RAC will review research proposals from CVSG Participants that request CVSG 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 CVSG 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 CVSG 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 CVSG on the SVS PSO National RAC.
- 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 CVSG meetings, prepares an annual budget and is responsible for the overall operations of the CVSG between meetings of the EC. The Medical Director will represent CVSG on the SVS PSO National Governing Council unless the EC decides to elect someone else in the region.
- Staff Members may be hired by the EC to meet organizational and analytical needs of CVSG, 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. CVSG Staff may include but are not restricted to statisticians, data analysts or administrative assistants.
- Shared Data Ownership: Each CVSG 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 CVSG use of non-identifiable data submitted by Members for purposes other than the quality improvement functions performed by CVSG, 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 CVSG and must be adhered to by all Members and Participants:
- All activities of the CVSG must be consistent with the Mission Statement. All data reports that compare clinical outcomes of physicians or hospitals must be anonymous, as specified in the PSQIA. All Participants in the CVSG 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 that 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 the SVS PSO.
- Each Member and Participant agrees that comparative data can never be used for competitive marketing. Thus, benchmarking reports that compares hospitals or physicians can never be published, consistent with the PSQIA.
- Each Member and Participant must agree 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 must agree 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 CVSG 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 CVSG regional data may be made by any CVSG Participant, and shall be considered by the EC after review by the RAC. If approved by the EC such projects may proceed. All CVSG Members conducting such research must agree to abide by all CVSG confidentiality rules, all HIPAA regulations, and all PSQIA regulations that are relevant to protecting the privacy of both patients and the member hospitals and physicians, none of whom shall be identified in any publication. All resulting publications and presentations shall be authored by the specific participating researchers from the CVSG and carry the author byline “on behalf of CVSG and the Principal Investigator of 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.