2. Key Conferences to Improve Quality in the Pediatric Cath Lab

3.  Morbidities, mortalities, and “near misses” ◦ Goal to reduce untoward events, stimulate practice improvement  Review of routine cases ◦ Goal to discuss/determine practice patterns, techniques and indications ◦ Link current practices to best practices ◦ Facilitate interdisciplinary collaboration  Education ◦ Goal to promote competence and understanding among attendees ◦ New technology/new techniques

4.  Number and frequency can be tailored by institution to cover required topics  Examples of conference schedules: ◦ 3 conference format:  1. M & M  2. Case review  3. Cath lab teaching ◦ 2 Conference format:  M & M and case review together; teaching as a separate conference  M & M separately; case review as part of teaching conference

5.  Invasive Cardiology Morbidity and Mortality (Cath Lab M&M) ◦ Separate from clinical cardiology M&M ◦ Open review and assessment of cath lab complications and in-hospital events following invasive cardiovascular procedures  Invasive Case Review Conference (Case Review) ◦ Open review of random sample of cases ◦ Diagnostic and interventional cases  Catheterization Laboratory Educational Conference ◦ Regular, frequent, formal educational events ◦ Focus on cath lab practice and issues ◦ Opportunity to discuss management of complex patients

6.  Essential to link your current practices to best practices  Foster interdisciplinary collaboration  Helpful in maintaining CME  Required by Joint Commission  Needed for Ongoing Professional Performance Evaluations (OPPEs), a Joint Commission requirement to assess operator performance 1  Required by ACGME if a fellowship training program 2 1 http://www.jcrinc.com/E-dition-Home/ 2 http://www.acgme.org

7.  Should occur regularly  Inclusive of all participants: encourages dialogue among participants  Fosters non-punitive environment with a focus on process improvement  Must be independent – no vendor sponsorship

8.  Essential to achieve meaningful practice improvement  Opportunity to review adverse events with peers  Engages multiple stakeholders: physicians, allied health, other disciplines

9.  Case identification should be unbiased  Quality officer (designated MD) or independent cath lab person should identify all cases with complications in review period  Case selection based on complications ◦ All deaths within 30 days of the procedure are reviewed at the next conference. ◦ All major complications, defined by ACCF/SCAI 1,2, and/or state reporting requirements, are reviewed ◦ Prospectively select other complications, aligned with process/quality improvement projects 1 American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards. J Am Coll Cardiol 2001; 2170-2214 2 Complications of Pediatric Cardiac Catheterization: a review in the current era. Catheter Cardiov Interv 2008(72); 278-285

10.  Meet at least quarterly, more often if possible  Attendance by all cath lab physicians mandatory ◦ Everyone working in cath lab should be invited to attend, their input is valuable ◦ The Joint Commission mandates a comprehensive, inclusive approach to event reviews 1  Multidisciplinary: bring in all relevant care providers for specific complications (anesthesia, ICU, etc)  Case presentations by fellow/resident if training program, otherwise attending of record or consider alternative attending as written documents by responsible physician may be discoverable if legal action 2  Responsible MD must be present when case reviewed. 1 www. Jcrinc.com/E-dition-Home/ 2 Wei, M. J Health Law 2007; Vol 40: 1

11.  Cases reviewed for the following: ◦ Appropriateness of case selection/indication 1,2 ◦ Adequacy of procedural decision making ◦ Promptness of complication recognition ◦ Appropriateness/efficiency of measures made to treat and/or limit complication ◦ Assess operator vs. system vs. patient related issues (risk adjustment) in causation of the complication ◦ Comparison to known literature and existing benchmarks for given complication if known 3 1 Indications for Cardiac Catheterization and Intervention in Pediatric Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2011; 123: 2607-2652 2 ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease. Circulation 2008; 118:e714-e833. 3 Complications of Pediatric Cardiac Catheterization; a review in the current era. Catheter Cardiov Interv 2008; 72: 278-285.

12.  Keep sign in sheet and case review forms with response/action plans  Create a mechanism to track complications ◦ Source data for institutional data base ◦ Source data for national/international data base/registries 1  Opportunity for CME with appropriate documentation 2 1 www.ncdr.comp/impact/ 2 www. acgme.org

13.  Assure indications for invasive procedures and intra-procedure decision-making conform to guidelines ◦ Review both angiography and hemodynamic information  Permits learning from others’ routine cases, not just complication cases  Independent criteria provide objective quality measures 1,2  Non-punitive: the goal is process improvement ◦ Learn from past mistakes and successes 1 Indications for Cardiac Catheterization and Intervention in Pediatric Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation. 2011; 123: 2607-2652. 2 ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease. Circulation. 2008; 118:e714-e833.

14.  Determine frequency (weekly, monthly, quarterly)  Designate responsible MD or cath lab manager, Quality Officer to select random cases for review ◦ Consider identifying a moderator  Cases reviewed openly, in group, with discussion  Never review a case when responsible MD away  Keep track of progress (e.g., appropriate indication, adequate hemodynamic assessment performed) and update the group on progress

15.  Provides for continued professional development  Can help meet ACGME core curriculum requirements for fellows 1  Venue for faculty and fellow development 1 www.acgme.org

16.  Designate responsible MD (eg. Cath Lab Director, Fellowship Program Director)  Regular event: hold each week, same time and place  Review cases performed ◦ Findings ◦ Patient outcomes ◦ Complications (identify cases for a focused M&M review)  Review upcoming cases ◦ Review existing data (clinical, imagine, previous catheterization data) ◦ Case planning (diagnostic and/or therapeutic) ◦ Review preparedness for case (staffing, equipment needs, etc) Cath Conference: how to make it happen

17.  Consider review and presentation of existing literature on particular topic as point of teaching ◦ Discuss actual management and other possible strategies for optimal patient management  Encourage attendance by non-cath lab MDs – to inform all care providers, stimulate discussions  Sign-in sheets for attendance.  Consider CME credit application 1 Cath Conference: how to make it happen 1 www.accme.org

18.  Key conferences required by Joint Commission, facilitate practice improvements, continuing medical education, professional development  To be successful, they must be: ◦ Regular ◦ Inclusive ◦ Non-punitive ◦ Focused on practice improvement