Mid-America VSG: By-Laws

Bylaws of the Mid-America Vascular Study Group

I. Mission Statement

The Mid-America Vascular Study Group (MAVSG) 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 group strives to continuously improve the quality, safety, effectiveness and cost of caring for patients with vascular disease.

II. Membership

Hospitals and physicians performing any of the vascular procedures recorded by MAVSG are eligible for full membership if they are located within the central United States. Full Membership requires that the member hospital or physician follow the policies and procedures established by MAVSG (see Section VI). If a hospital or hospital system acts as the contracting agent for membership in MAVSG, physicians who perform vascular procedures in that hospital are eligible to participate. A hospital, hospital system, physician, or physician group with existing contracts with the SVS PSO and M2S which is approved for full membership is hereinafter referred to as a “MAVSG Member”. A majority vote of the MAVSG Executive Committee is required to approve full membership of new MAVSG Members. MAVSG members and physicians agree to adhere to all policies and procedures of the SVS PSO.

III. Patient Safety Organization

The MAVSG is an unincorporated association of MAVSG Member hospitals and physicians that use the Society for Vascular Surgery® Patient Safety Organization (SVS PSO) as the vehicle for quality improvement and the M2S, Inc. Pathways product for data collection and quality report generation. Contracts are required between MAVSG Members and the SVS PSO, M2S, and the Cadence Health Foundation, which acts as the fiduciary agent for MAVSG for regional staff and projects. SVS PSO is a Patient Safety Organization, as defined by The Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41), established by the Society for Vascular Surgery (SVS) as a limited liability company and implemented to protect the confidentiality of all data and resulting patient safety work product resulting from quality improvement efforts of the PSO and its member regional study groups. M2S, Inc. provides web-based services to SVS PSO related to the MAVSG registry, under an administrative services agreement. Under the relevant agreements with each MAVSG Member, SVS PSO will perform common data management services for MAVSG Members, as determined by the MAVSG Quality Committee of the SVS PSO.
Each MAVSG Member must have contracts with SVS PSO and M2S, Inc. (the Hospital Contracts), which affirms adherence to the MAVSG Bylaws. The form of the Hospital Contracts between SVS PSO
and M2S, Inc., and MAVSG Members must be approved by the MAVSG Executive Committee, including the costs for SVS PSO and M2S services. The Hospital Contracts shall include annual charges, based on hospital procedure volume or number of participating physicians, to be paid to SVS PSO and M2S for web-based data collection, data management and report generation. In addition, the Executive Committee establishes an annual fee for MAVSG hospitals to fund semiannual meetings and MAVSG staff, which is paid to the Cadence Health Foundation, through an annual contract with each MAVSG Member. Yearly dues levels will be established when appropriate, but in no case will exceed $2000 or 20% of a MAVSG Member’s SVS PSO subscription fee, whichever is less.

IV. Committees and Staff

A. Executive Committee:

The business of the MAVSG shall be managed by or under the direction of an Executive Committee, which may exercise all the powers of the MAVSG except as otherwise determined by two-thirds of the MAVSG Members. The Executive Committee conducts the business of the MAVSG and makes all decisions on behalf of the MAVSG, including oversight of budgets, contracts, publications, relationships with outside parties, requests for membership, and the general direction of the association. In the event of a vacancy in the Executive Committee, the remaining members of the Executive Committee may exercise the powers of the full Executive Committee until the vacancy is filled. The Executive Committee may designate other committees as necessary to conduct the business of MAVSG.
The MAVSG Executive Committee consists of one representative appointed by each MAVSG Member as well as the Medical Director, Project Manager and Epidemiologist, all of whom are voting members of the Committee. The Executive Committee 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 Executive Committee. The Executive Committee oversees the interaction of MAVSG with the SVS PSO and M2S, Inc., including costs and contractual details for MAVSG Member participation in the SVS PSO. It approves research studies and publications, relationships with outside parties, requests for membership, deidentified data distribution for research or sale to commercial entities and the general direction of the MAVSG.
A quorum of the Executive Committee consists of representatives of at least two-thirds of the MAVSG Members, which is necessary to conduct business. Each contracted entity (MAVSG Member) is allowed one vote on the Executive Committee. 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 Executive Committee member cannot attend a meeting, the MAVSG Member may designate an alternate, who shall have full voting rights. Any Executive Committee member with a real or perceived conflict of interest with respect to any item under consideration shall recuse him or herself from any vote on that topic. Minutes of the Executive Committee meetings are distributed electronically or via the MAVSG website (www.vascularqualityinitiative.org/mavsg) to all hospital and physician members of the MAVSG.

B. Arterial Quality Committee:

The MAVSG Arterial Quality Committee consists of physicians, analysts, and administrative personnel elected by the MAVSG Executive Committee. The chair of the MAVSG Arterial Quality Committee, appointed by the Executive Committee, represents the MAVSG at the SVS PSO and the chair of the MAVSG Arterial Quality Committee must sign agreements to abide by all confidentiality rules of the SVS PSO. The MAVSG Quality Committee is responsible for all decision making concerning patient safety work product production using MAVSG regional arterial procedure data within the SVS PSO, including types of analyses, reports, benchmarking, and risk adjustment to be conducted by the SVS PSO. The Quality Committee represents the interests of all MAVSG Member hospitals and physicians on the SVS PSO, and oversees all SVS PSO arterial quality improvement activities for the MAVSG region.

C. Venous Quality Committee:

The MAVSG Venous Quality Committee consists of physicians, analysts, and administrative personnel elected by the MAVSG Executive Committee. The chair of the MAVSG Venous Quality Committee, appointed by the Executive Committee, represents the MAVSG at the SVS PSO and the chair of the MAVSG Venous Quality Committee must sign agreements to abide by all confidentiality rules of the SVS PSO. The MAVSG Venous Quality Committee is responsible for all decision making concerning patient safety work product production using MAVSG regional venous procedure data within the SVS PSO, including types of analyses, reports, benchmarking, and risk adjustment to be conducted by the SVS PSO. The Venous Quality Committee represents the interests of all MAVSG Member hospitals and physicians on the SVS PSO, and oversees all SVS PSO venous quality improvement activities for the MAVSG region.

D. Research Committee:

A standing Research Committee will be established with a chair elected by the Executive Committee. The responsibility of the Research Committee will include receiving, reviewing, and approving MAVSG research proposals. The Research Committee is also responsible for monitoring and assuring compliance with MAVSG research rules (see Section VII below).

E. Staff:

  1. The Medical Director is a vascular surgeon nominated by the Executive Committee and elected by a majority vote of the full membership of the Executive Committee to a three year renewable term. The Medical Director chairs the Executive Committee, prepares the agenda for MAVSG meetings, prepares an annual budget and is responsible for the overall operations of the MAVSG between meetings of the Executive Committee.
  2. Staff Members may be hired by the Executive Committee to meet organizational and analytical needs of MAVSG. Staff members are selected by the Executive Committee and their percentage effort and associated salary are set by the Executive Committee, consistent with the annual budget. A 2/3 majority vote of the Executive Committee is required to hire a staff member. MAVSG Staff shall include but are not restricted to:
    1. A Project Manager, who is responsible for day-to-day operation of the MAVSG under the supervision of the Medical Director, including but not limited to support to MAVSG Member hospitals regarding web-based data submission and report generation, as well as preparing for MAVSG meetings, coordinating quality improvement activities and all other operational functions of the group.
    2. An Epidemiologist, who is responsible for oversight of the analytic and statistical functions of the group.
    3. A Statistician, who is responsible for the analyses of data necessary to conduct quality improvement activities.

V. Shared Registry Data Ownership

Each MAVSG Member owns the data that it submits to the MAVSG registry via the SVS PSO, and is entitled to specify and control the use of its data in the manner set forth in the Hospital Contract. Thus, any use of a MAVSG Member’s data by the MAVSG for purposes other than quality improvement research or any of the standard quality assurance functions performed by the MAVSG shall require the prior consent of the MAVSG Member, in the manner set forth in the Hospital Contract.

VI. Policies

The following principles guide the function of the MAVSG and must be adhered to by all MAVSG Members.

  1. All activities of the MAVSG must be consistent with the mission statement above. All data reports that compare physicians or hospitals must be anonymous unless identification of specific
    hospitals or physicians is unanimously approved by the involved MAVSG Members or physicians. Any reports that identify hospitals or physicians are considered quality assurance documents. All members of the MAVSG agree to keep such information strictly confidential.
  2. Each physician member must submit data for all consecutive procedures that are recorded by MAVSG and must agree to submit office claims data on a periodic basis to allow an audit to
    ensure accurate and complete data entry.
  3. Each MAVSG Member agrees to submit ICD-9 based claims data on a periodic basis to allow an audit to ensure accurate and complete data entry.
  4. Each MAVSG Member and physician must submit complete data forms, including all elements of the MAVSG registry for all eligible procedures, using a web-based system approved by the MAVSG, including follow-up data at one year, or other time points established by the MAVSG.
  5. Each MAVSG Member and physician agrees that comparative data can never be used for competitive marketing. Hospitals and physicians own their own data, and can publish such data with the indication that it has been audited by the MAVSG. However, they may not publish data provided in benchmarking reports that compare their hospital or practice with other groups in the MAVSG.
  6. Each hospital and physician member must agree to follow the MAVSG Confidentiality Manual which is available on the MAVSG website (www.vascularqualityinitiative.org/mavsg), and is designed to prevent the disclosure of any patient identifiable information, as well as any hospital or physician identifiable information. Further, each MAVSG hospital and physician member agrees to follow all regulations contained within the Health Insurance Portability and Accountability Act (HIPAA) and the Patient Safety Quality Improvement Act (PSQIA).
  7. Failure to adhere to these policies may result in loss of membership in MAVSG for a hospital or physician, if so determined by a majority vote of the Executive Committee.

VII. Research

Analyses will be regularly performed by the MAVSG to provide feedback to member hospitals and physicians for purposes of quality improvement within the SVS PSO. These may yield useful information that could benefit the medical community at large, and warrant scientific publication or presentation. Proposals for specific research projects using shared regional data may be made by any MAVSG Member hospital or physician, and shall be considered by the Research Committee. If approved by the Research Committee such projects may proceed. All MAVSG Members conducting such research agree to abide by all MAVSG confidentiality rules, all HIPAA regulations, and all PSQIA regulations that are relevant to protecting the privacy of both patients and the MAVSG 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 individuals from the MAVSG and carry the author byline “on behalf of the Mid-America Vascular Study Group.” Each participant in such research must sign a statement that attests to these agreements.

VIII. Amendments

Bylaws may be amended by a vote of two-thirds of the full membership of the Executive Committee, provided that such amendments are circulated electronically and on the MAVSG website at least 30 days prior to their consideration. Any amendments published on the MAVSG website shall be deemed incorporated herein by reference.