l. Mission Statement
The Rocky Mountain Vascular Quality Initiative (RMVQI) 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 RMVQI strives to continuously improve the quality, safety, effectiveness and cost of vascular healthcare.
Hospitals or physicians groups that participate in the Society for Vascular Patient Safety Organization (SVS PSO) are eligible for membership in RMVQI if they are located within or adjacent to the following states: Arizona, Colorado, Idaho, Montana, New Mexico, Nevada, Utah or Wyoming. Any new contracting entity in this geographic area who contractually elects to join RMVQI is automatically a welcome member. Hospitals or physician groups or physicians contracted with the SVS PSO that participate in RMVQI are termed “Members.” Clinicians, hospital administrators, data managers, and research/quality personnel who participate in RMVQI are termed “Participants.” They are required to follow the policies and procedures established by RMVQI (see Section VII). If hospitals act as the contracting entity with RMVQI (see III.), any physicians who perform vascular procedures and submits cases to the VQI may participate in RMVQI.
The RMVQI 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. RMVQI regional activities, including semiannual meetings, administrative activity and regional data analyses, are funded by RMVQI Members through an annual fee established by the Executive Committee Industry Grants, or member hospitals. If the RMVQI votes to fund through annual member fee, each RMVQI Member must contract with the agreed upon fiduciary agent for RMVQI 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 RMVQI Executive Committee (EC) consists of one representative appointed by each RMVQI Member, as well as the Medical Director, all of whom are voting members. The EC conducts the business of the RMVQI and makes all decisions on behalf of the RMVQI, 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 RMVQI with the FEDUCIARY AGENT, including costs and contractual details for RMVQI Member participation. The EC may designate other committees as necessary to conduct the business of RMVQI.
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 RMVQI 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 RMVQI Member may designate an alternate, who shall have full voting rights, this person does not need to by a physician. Minutes of the Executive Committee meetings are distributed electronically or via the RMVQI website to all Members and Participants of the RMVQI.
2) Arterial/Venous Quality Committee (QC):
The RMVQI Quality Committee (QC’s) consists of RMVQI 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 RMVQI. This includes the development of specific quality improvement projects for approval by the EC; organizing quality presentations at the RMVQI 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 RMVQI will represent RMVQI on the SVS PSO National Quality Committees.
3) Research Advisory Committee (RAC):
The Research Advisory Committee (RAC) consists of RMVQI 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 RMVQI. 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 RMVQI Participants. The RAC will review research proposals from RMVQI Participants that request RMVQI 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 RMVQI 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 RMVQI 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 RMVQI 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 RMVQI meetings, prepares an annual budget and is responsible for the overall operations of the RMVQI between meetings of the EC. The Medical Director will represent RMVQI 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 RMVQI, 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. RMVQI Staff may include but are not restricted to statisticians, data analysts or administrative assistants.
V. Shared Data Ownership
Each RMVQI 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 RMVQI use of non-identifiable data submitted by Members for purposes other than the quality improvement functions performed by RMVQI, 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 RMVQI and must be adhered to by all Members and Participants:
1) All activities of the RMVQI 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 RMVQI agree to follow the rules of the PSQIA and keep such information strictly confidential.
2) 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.
3) 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.
4) 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.
5) 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.
6) 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).
7) Failure to adhere to these policies may result in loss of membership in RMVQI for a hospital or physician if so determined by a majority vote of the EC.
Proposals for health services research projects using shared, non-identifiable RMVQI regional data may be made by any RMVQI Participant, and shall be considered by the EC after review by the RAC. If approved by the Executive Committee such projects may proceed. All RMVQI Members conducting such research must agree to abide by all RMVQI 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 RMVQI and carry the author byline “on behalf of RMVQI and the Principal Investigator of such research projects must sign a statement that attests to these agreements.
Bylaws may be amended by a vote two thirds of the full membership of the EC provided that such amendments are circulated electronically at least 30 days prior to their consideration.