Midwest Vascular Collaborative Bylaws
I. Mission Statement
The Midwest Vascular Collaborative (MVC) is a voluntary, cooperative group of clinicians, hospital systems representatives, and research personnel organized to improve the care of patients with vascular disease. By collecting and exchanging information, MVC strives to continuously improve the quality, safety, effectiveness and cost of caring for patients with vascular healthcare.
Hospitals, physicians and physician groups who participate in the Society for Vascular Patient Safety Organization (SVS PSO) are eligible for membership in MVC if they are located within Midwestern states, to include Indiana, Ohio, Illinois and Kentucky. Any new contracting entity in this geographic area who contractually elects to join MVC is automatically a welcome member. Hospital, physician or physician groups contracted with the SVS PSO that participate in MVC are termed “Member.” Clinicians, hospital administrators, and research personnel who participate in MVC are termed “Participants.” Members and Participants are required to follow the policies and procedures established by MVC (see Section VII). If hospitals act as the contracting entity with MVC (see III.), any physicians who perform vascular procedures in that hospital and submits cases to the VQI may participate n in the MVC.
The MVC is an unincorporated association of Members, each of whom contracts 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. MVC regional activities, including, semiannual meetings, administrative activity and regional data analyses, are funded by MVC Members through either an annual fee established by the MVC Executive Committee, Industry Grants, member hospitals, or other funding sources. If the MVC votes to fund through annual member fee, each MVC Member must contract with the agreed upon fiduciary agent for MVC 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 MVC Executive Committee (EC) consists of one representative a appointed by each MVC Member, as well as a Medical Director, all of whom are voting members. In the event of a vacancy in the EC, the remaining EC Members will have the authority to exercise the powers of the full EC until the vacancy is filled. The Medical Director, who is a physician, shall serve as chair of the EC. The Medical Director is separate from the EC members who are appointed by each participating facility. (See item IV. 4a.) The EC manages and conducts the business of the MVC and makes all decisions on behalf of the MVC, including oversight of budgets, contracts, publications, relationships with outside parties, requests for membership, and the general direction of the association. The EC may appoint one or more fiduciary agents from time to time and shall oversee the interaction of MVC with such fiduciary agents, if any, including costs and contractual details for MVC Member participation. The MVC will assign the Methodist Health Foundation (MHF) as the initial fiduciary agent. The EC may designate other committees as necessary to conduct the business of MVC.
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 MVC 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 MVC Member may designate an alternate, who shall have full voting rights. Minutes of the Executive Committee meetings are distributed electronically or via the MVC website to all Members and Participants of the MVC.
2) Arterial/Venous Quality Committees (QC’s):
The MVC Quality Committees (QC’s) consists of MVC Members, Participants, and a Chair, all of whom are appointed by the Medical Director with approval of the EC. The Chair must be a physician. The term of membership and number of members is determined by the EC. The mission of the QC is to oversee quality improvement efforts in MVC. This includes the development of specific quality improvement projects for approval by the EC; organizing quality presentations at the MVC 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 and other activities as requested by the EC. The chairs of the Arterial and Venous MVC will represent MVC on each of the SVS PSO Quality Committee.
3) Research Advisory Committee (RAC):
The Research Advisory Committee (RAC) consists of MVC Members and Participants, including a Chair, all of whom are appointed by the Medical Director with approval of the EC. The Chair may be either a Doctor of Medicine (M.D.) or a Doctor of Philosophy (Ph.D.). Members of the RAC will have interest and expertise in the design, conduct, interpretation, and presentation of analytic projects involving data collected by MVC. 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 MVC Members and Participants. The RAC will review research proposals from MVC Members and Participants that request MVC 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 MVC 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 MVC Members and 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 MVC 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, with a quorum of the EC approval of additional terms. The Medical Director chairs the EC, prepares the agenda for MVC meetings, prepares an annual budget and is responsible for the overall operations of the MVC between meetings of the EC. The Medical Director is not considered a hospital appointed representative, to the EC. The Medical Director votes, only in cases of breaking a tie or to achieve a quorum. If a member of the EC is appointed to the office of Medical Director, the EC member must relinquish his or her voting rights and assign another MVC member, from his or her participating facility, to represents that facility on the EC. The Medical Director will represent the MVC 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 MVC, 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. MVC Staff may include but are not restricted to statisticians, data analysts or administrative assistants.
V. Shared Data Ownership
Each MVC 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 MVC use of non-identifiable data submitted by Members for purposes other than the quality improvement functions performed by MVC, 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 MVC and must be adhered to by all Members and Participants:
- All activities of the MVC 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 MVC 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 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 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 MVC.
- 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.
- 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 MVC, if so determined by a majority vote of the EC.
Proposals for health services research projects using shared, non-identifiable MVC regional data may be made by any MVC Member and shall be considered by the EC after review by the RAC. If approved by the EC such projects may proceed. All MVC Members conducting such research agree to abide by all MVC 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 MVC and carry the author byline “on behalf of Midwest Vascular Collaborative (MVC).” The Principal Investigator of, and each Participant in, such research projects must sign a statement that attests to these agreements.
These 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.