I. Mission Statement
The Pacific Northwest Vascular Study PNWVSG (PNWVSG) is a voluntary, cooperative PNWVSG of clinicians, hospital administrators, and research personnel organized to improve the care of patients with vascular disease. By collecting and exchanging information, the PNWVSG strives to continuously improve the quality, safety, effectiveness and cost of vascular healthcare.
Hospitals or physician or physician groups that participate in the Society for Vascular Patient Safety Organization (SVS PSO) are eligible for membership in PNWVSG if they are located within Oregon, Washington, Idaho, Montana, Alaska, Hawaii, and Canada. Any new contracting entity in this geographic area who contractually elects to join PNWVSG is automatically a welcome member. Hospitals or physician groups or physicians contracted with the SVS PSO that participate in PNWVSGs that are then termed “Members.” Clinicians, hospital administrators, and research personnel who participate in PNWVSG are termed “Participants.” They are required to follow the policies and procedures established by PNWVSG (see Section VII). If hospitals act as the contracting entity with PNWVSG (see III.), any physicians who perform vascular procedures and submits cases to the VQI may participate in PNWVSG.
The PNWVSG 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. PNWVSG regional activities, including semiannual meetings, administrative activity and regional data analyses, are funded by PNWVSG Members through an annual fee established by the Executive Committee, industry Grants, or member hospitals. Each PNWVSG Member must contract with the fiduciary agent for PNWVSG to receive these payments, when so deemed necessary by the EC. 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 PNWVSG Executive Committee (EC) consists of one representative appointed by each PNWVSG Member, as well as a Medical Director, all of whom are voting members. The EC conducts the business of the PNWVSG and makes all decisions on behalf of the PNWVSG, 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 PNWVSG with the fiduciary agent, including costs and contractual details for PNWVSG Member participation. The EC may designate other committees as necessary to conduct the business of PNWVSG.
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 two-thirds of the PNWVSG 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 PNWVSG Member may designate an alternate, who shall have full voting rights. Minutes of the Executive Committee meetings are distributed electronically or via the PNWVSG website to all Members and Participants of the PNWVSG.
2) Arterial and Venous Quality Committees (AQC and VQC):
The PNWVSG AQC and VQC consist of PNWVSG 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 AQC and VQC is to oversee quality improvement efforts in PNWVSG. This includes the development of specific quality improvement projects for approval by the EC; organizing quality presentations at the PNWVSG 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 EC shall appoint a member of the PNWVSG AQC and VQC to represent PNWVSG on the SVS PSO Quality Committees. The chairs of the Arterial and Venous QC’s will represent the PNWVSG on the SVS PSO National Quality Committee.
3) Research Advisory Committee (RAC):
The Research Advisory Committee (RAC) consists of PNWVSG 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 PNWVSG. 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 PNWVSG Participants. The RAC will review research proposals from PNWVSG Participants that request PNWVSG 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 PNWVSG 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 PNWVSG 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 the PNWVSG 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 PNWVSG meetings, prepares an annual budget and is responsible for the overall operations of the PNWVSG between meetings of the EC. The Medical Director will represent the PNWVSG on the SVS PSO National Governing Council unless the EC decides to elect someone else in the region.
b) Staff Members(optional first two years) may be hired by the EC to meet organizational and analytical needs of PNWVSG, or such services may be contracted from an outside entity. Staff members are selected by the Medical Director with approval by the EC. PNWVSG Staff may include but are not restricted to statisticians, data analysts or administrative assistants.
V. Shared Data Ownership
Each PNWVSG 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 PNWVSG use of non-identifiable data submitted by Members for purposes other than the quality improvement functions performed by PNWVSG, 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 PNWVSG and must be adhered to by all Members and Participants:
- All activities of the PNWVSG 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 PNWVSG 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 PNWVSG.
- 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 PNWVSG for a hospital or physician PNWVSG, if so determined by a majority vote of the EC.
Proposals for health services research projects using shared, non-identifiable PNWVSG regional data may be made by any PNWVSG Participant, and shall be considered by the EC after review by the RAC. If approved by the Executive Committee such projects may proceed. All PNWVSG Members conducting such research must agree to abide by all PNWVSG 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 PNWVSG and carry the author byline “on behalf of PNWVSG 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.