Three Steps for a Quality, Proactive Cardiovascular Cath Lab Peer Review

As cardiac cath lab professionals, we must ensure quality for our patients. Through nationally published guidelines, we perform concisely and consistently to ensure the best outcomes.

Today, cardiology procedures are scrutinized more than ever, creating an imperative to ensure high-quality programs. Implementing a proactive peer review program for your cardiovascular program is one of the key elements to ensure quality outcomes. 

Peer review is the evaluation of scientific, academic, or professional work by others working in the same field. When cardiac cath labs (CCLs) institute peer review, many struggle with the issue of how to design the peer review process to guarantee the best cardiac care for each patient. Designing and implementing any new process starts with strong leadership. Leadership establishes the framework necessary to ensure the sanctity of exceptional, patient-centric quality care.

The challenges of implementing an effective cardiology peer review program include:

• Designing an objective, measureable, timely process;
• Engaging all cardiovascular clinicians and team members in the quality outcomes initiative;
• Reducing complexity of the process, keeping it as simple and as possible;
• Addressing nationally published recommendations and guidelines, i.e.,  Appropriate Use Criteria (AUC) documentation;
• Validating the peer review process in the changing healthcare environment.

Partnering with the Accreditation for Cardiovascular Excellence (ACE) takes cath labs from good to great in achieving quality patient care by:

• Elevating the performance of the CCL through appropriate care integration;
• Delivering third-party validation, including effective peer review;
• Engaging physicians in the quality outcomes process;
• Helping to mitigate risk. 

Elevating cath lab quality performance

Payer organizations may mandate CCL participation in national databases such as the National Cardiovascular Data Registry (NCDR)¹ to benchmark CCL programs. This requirement stems from the assumption that the submitted data are accurate. But how do we certify accuracy? What happens when the data are not found in the patient chart? A recent report presented by ACE (Figure 1) determined that although CCLs provide excellent care to patients, most do not meet reporting standards.² 

Data tools

Accurately documenting the factors that support the determination of appropriate use is essential to improving CCL performance and moderating risk for all stakeholders. It is important that CCL professionals stay cognizant of quality data standards, and include complication rates and major adverse cardiac and cerebrovascular events (MACCE). The Society for Cardiovascular Angiography and Interventions Quality Toolkit (SCAI-QIT) is an excellent reference to capture appropriate documentation.³ ACE published standards are another useful reference to target key processes that impact quality and outcomes.⁴ In addition, a valuable overview on requirements for a comprehensive continuous quality improvement (CQI) process in interventional cardiology is: “Quality Assessment and Improvement in Interventional Cardiology: A Statement of the Society of Cardiovascular Angiography and Interventions, Part 1, Standards for Quality Assessment and Improvement in Interventional Cardiology.”⁵

Organizational risk mitigation

Despite high levels of scrutiny, lack of complete data and transparency continue to affect CCL performance. Peer review breaks down because competition, camaraderie or conflict of interests between physician groups is not addressed in the process design. When peer review is unsuccessful in validating established quality systems, a reactive process typically ensues. Peer review should not be reserved for the situations when poor outcome or appropriate patent care is in question. Organizational risk can be mitigated by proactively performing peer review to determine factors that are barriers to securing optimal outcomes. ACE cardiology peer review experts recommend a process that is performed, discussed and implemented at all levels and amongst all disciplines within the cardiovascular program. 

Expertise in cardiovascular peer review

Internal peer review processes are critical; however, external validation may compliment these processes. The most objective method for validating a peer review program is to partner with an organization that includes cardiology expertise such as the ACE E3 Expert External Evaluation program. In this program, ACE cardiology specialists guide the development of an integrated quality program by providing a thorough and in-depth review of documentation to engage physicians in achieving consensus in the quality outcomes process. Clinician experts collaborate from within the physician team, helping to reduce complexity and focus the CCL on vital quality indicators. ACE E3 peer review integrates AUC standardization (Figure 2), eliminates bias, and validates quality of patient services. 

Establishing a patient-centric CCL peer review program 

A model peer review program can be based on a three-step process:

1) Form your TEAM/define your process

Regular quality assurance meetings are a requirement for ACE accreditation.⁴  Organize a team to meet monthly that includes CCL leadership. This group is often called the “Cardiology Council” or “Cardiovascular Council.” The attendees may include: 

• Hospital administration 
• A cardiac surgeon
• The ER medical director 
• The CCL director and manager 
• The medical director 
• The director of quality 
• A charge nurse
• A lead tech 
• The radiation safety officer

Confirm with the Cardiology Council that peer review is always peer protected to eliminate the possibility of inappropriate disclosure. Formalize a written protocol to address any significant findings before implementing peer review if such a policy does not exist in your organization. It is best to involve the organization’s legal team and then obtain consensus from all cardiology stakeholders. 

2) Review the SCAI QIT and design/implement peer review

By reviewing operator performance and comparing clinical decision-making to nationally accepted best practices, physician peer review plays a critical role in CQI. Begin with an Angiographic Peer Review comprised of randomly selected, de-identified cases for each operator in the lab. Use a simplified, standardized form to report findings (See Figure 3⁶ for an example) or create/enhance your form using the valuable information from the SCAI website and in the SCAI Toolkit.³ Validate and analyze your program’s National Cardiovascular Data Registry (NCDR) data. Be prepared to discuss opportunities for improvement with solutions to implement at each council meeting.

3) Intra-disciplinary peer review

• Implement peer review within all disciplines working in the CCL.
• Assess overall RN documentation to verify:
• Repeated verbal orders, time, date and signature.
• All medications have been accurately given and documented.
• Accuracy of auto-populated vital signs.
• Patient’s acceptable level of pain documented prior to the procedure.
• Patient’s pain level re-assessed after each pain medication and/or intervention.
• The implementation of a visual assessment/RN peer review to ensure that all medications are labeled on and off the sterile field.
• Have your lead radiologic technologist (RT) review the CCL procedure log and CCL report to include documentation of total contrast and fluoro time to ensure:
• Appropriate follow-up per your organization’s written policy for patients who have received higher doses of contrast and/or radiation. 
• A standard process to track total dosage of all contrast and radiation exposure during the entire hospital stay. 
• Some organizations now incorporate this information into their imaging order entry system.

Implementation by lead RT of a visual assessment of radiation exposure in patients and staff is “as low as reasonably achievable” (ALARA) at all times. 

Involve finance department leadership to determine if cardiac catheterizations or lab procedures are being denied. If so, identify the root cause. ACE data³ shows that denials are often due to a lack of appropriate documentation. 

ACE E3 supports peer review by assisting the CCL to compile documentation and discuss interdisciplinary peer review findings at each Cardiology Council meeting.

In summary, be proactive. Start your three-step program for quality, improvement and peer review for the CCL now. ACE E3 exists to help you on that quality journey. You have to get real to heal. You and your patients will be glad you did! 

Sheree Schroeder has been a cardiovascular consultant for the past 7 years with 35+ years of critical care and cardiovascular nursing experience. She can be contacted at sschroeder@cvexcel.org.

ACE is a nonprofit organization sponsored by the American College of Cardiology Foundation (ACCF) and the Society for Cardiovascular Angiography and Interventions (SCAI), offering independent evaluation and monitoring of facilities that provide cardiovascular care. ACE is a physician-run board/organization.

Visit the ACE website for additional information and to schedule a complimentary one-hour consultation: www.cvexcel.org.

References

1. Data powering performance. National Cardiovascular Data Registry. Available online at https://www.ncdr.com/webncdr. Accessed February 8, 2013.
2. ACE: The first experience with process reviews. Available online at https://www.cvexcel.org/resources/ACE_Presentations/ACE_Process/player.html. Accessed February 6, 2013.
3. SCAI Appropriate Use Critera App. Available online at https://www.scai.org/QIT/Default.aspx. Accessed February 6, 2013.
4. ACE: Cath-PCI Standards Overview. Available online at https://www.cvexcel.org/CathPCI/Standards.aspx. Accessed February 6, 2013.  
5. Klein LW, Uretsky BF, Chambers C, Anderson HV, Hillegass WB, Singh M, Ho KK, Rao SV, Reilly J, Weiner BH, Kern M, Bailey S; Society of Cardiovascular Angiography and Interventions. Quality assessment and improvement in interventional cardiology: a position statement of the Society of Cardiovascular Angiography and Interventions, part 1: standards for quality assessment and improvement in interventional cardiology. Catheter Cardiovasc Interv. 2011 Jun 1; 77(7): 927-935. doi: 10.1002/ccd.22982.
6. Jackson VP, Cushing T, Abujudeh HH, Borgstede JP, Chin KW, Grimes CK, Larson DB, Larson PA, Pyatt RS, Thorwarth Jr WT. RADPEER^™ scoring white paper. J Am Coll Radiol. 2009 Jan;6(1):21-5. doi: 10.1016/j.jacr.2008.06.011. Available online at https://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Radpeer/ScoringWhitePaper.pdf. Accessed February 6, 2013.
7. American College of Cardiology Updates Appropriate Use Criteria Methodology. Available online at https://www.cardiosource.org/News-Media/Publications/Cardiology-Magazine/2013/02/AUC-of-Cardiovascular-Technology.aspx?w_nav=RI. Accessed February 22, 2013.