Group PQI Project
I. Participating as a Group of Diplomates
In response to requests from a number of practices to complete quality improvement initiatives as a group or groups of diplomates within a practice, the ABTS created a special category of MOC Part IV participation. Group participation in PQI is an important option because the scale is well-suited to address systems-based problems. Thus, it holds tremendous potential as a multiplier of MOC’s power to advance healthcare quality and safety. Group participation can also be more convenient and manageable for administrative purposes.
II. What Constitutes a Group?
The ABTS understands that a wide variety of group practice settings must be recognized and accommodated. Thus, for purposes of Group PQI project participation, the ABTS has defined “group” as:
“Two or more thoracic surgeons, sharing a common central organizational structure, who work together to provide patient care, regardless of individual contractual affiliations or relationships. These cardiothoracic surgeons may provide services at single or multiple facilities or locations in a variety of clinical settings, including hospitals and offices.”
Because Group PQI may inadvertently distance some participants from an intimate, hands-on experience, certain project-level and diplomate-level standards must be applied to ensure meaningful participation. The regional thoracic surgery regional QI groups are models for fulfilling Part IV MOC and active participants meet Part IV completely.
III. Group PQI Process Standards
A group practice quality improvement project shared among thoracic surgeons should have the potential to impact their individual practice behavior and/or system environments within the confines of their group practice. If a group of thoracic surgeons decides to participate in a systems-based PQI initiative, the following guidelines must be followed in order for all participants to receive PQI credit. These standards are intended to ensure meaningful participation of diplomates in group PQI.
One thoracic surgeon who is participating in MOC must be identified as the project or team leader for the group project. This will facilitate organizing meetings; taking attendance and keeping minutes of meetings; and coordinating data collection, analysis and review, as well as improvement planning and implementation.
- Each participating thoracic surgeon’s name must be documented along with project title, project description, and the start and end dates for the project.
- Credit for individual participation in a Group PQI project requires attendance at three or more group meetings (as described below for “Group-Designed Project Criteria”), with minutes taken and attendance documented for each participant. Such meetings are mandatory.
- Each participant must have access to all project documentation, including meeting minutes and any additional relevant data, which will facilitate reporting to the ABTS in the event of an audit.
- Each participant must fulfill meaningful participation requirements and, when a PQI project is completed, prepare a short paragraph of self-reflection, stating how the project positively impacted his or her practice and/or patients.
- Final sign-off of the project leader before receiving ABTS MOC Part IV credit is required. Each thoracic surgeon participating in and completing the project will receive individual PQI credit from the ABTS after an attestation is completed by the participant.
IV. Group PQI Project Standards
As with Individual PQI projects, Group PQI projects may be self-designed by the diplomates or selected from a variety of existing projects sponsored by national organizations and societies. The goals and measures of any project should be relevant to each diplomate’s practice, with the potential to improve care.
Group-designed PQI projects are conceived and formatted by the group to address a quality or safety gap in the group’s practice. Such projects do not require review of approval by the ABTS for use. However, certain constructs in the design and execution of the project must be observed, and the development process must be documented. The “Plan-Do-Study-Act” cycle, as described for Individual PQI and as modified below for use by Group PQI efforts, must be followed.
A major distinguishing feature of Group PQI, as compared to Individual PQI, is the requirement of group meetings to ensure meaningful engagement of participants in the process.
Group meetings also promote productive interactions among the participants in performing quality measurements and assessments and implementing practice-improvement actions relevant to the system in which the participants practice.
V. Examples of Group Projects
Link to: Example Group Thoracic Project
- Early Foley removal prior to thoracic epidural removal
- Increased incidence of urinary tract infection identified in NSQIP data addressed through a dedicated nursing education program
- Reduction in epidural utilization for thoracotomies through implementation of new pain control strategies: impact on length of stay
- Multidisciplinary effort to fast tracking esophagectomy patients and reduction in length of stay
- Analysis of our use of in-house versus outpatient barium swallow study after esophagectomy: increased hospital stay and minimal utility associated with in-house performance
- Between January 2008 and December 2012, a multicenter quality collaborative of cardiac surgeons in Michigan initiated a focus on blood conservation as a quality metric, with educational presentations and quarterly reporting of institutional-level perioperative transfusion rates and outcomes. This prospective cohort study was undertaken to determine the effect of that initiative on transfusion rates after isolated coronary artery bypass grafting (CABG).Transfusion rates continuously decreased for all blood products. RBC use decreased from 56.4% in 2008 (baseline) to 38.3% in 2012, FFP use decreased from 14.8% to 9.1%, and platelet use decreased from 20.5% to 13.4% (ptrend < 0.001 for all). (Michigan Society of Thoracic and Cardiovascular Surgeons)
- Off-pump coronary artery bypass (OPCAB) may be associated with improved outcomes when compared with on-pump coronary artery bypass. This study evaluates the use of a system for access and stabilization (SAS) with a coronary stabilizer as well as a clinical effectiveness quality initiative (CEQI) process regarding outcomes. This included the development of an expanded heart care team as well as standardization and refinement of perioperative care. Our aim was to evaluate morbidity and mortality of on-pump coronary artery bypass grafting (CABG) compared with OPCAB surgery using SAS in addition to a CEQI initiative. One-thousand two-hundred sixty-seven procedures were performed; 405 on-pump CABGs, 90 OPCABs pre-SAS, and 772 OPCABs with SAS, of which 552 were in the SAS + CEQI group. Statistically mortality was significantly lower in the SAS + CEQI vs the on-pump group (0.7% vs 3.0%, p < 0.01). The percentage of patients with prolonged ventilation was significantly lower statistically in the SAS + CEQI vs the on-pump group (4.2% vs 9.7%, p < 0.01). Statistically the length of stay was significantly lower in both SAS groups compared with the on-pump group (p < 0.01). (The Lankenau Hospital)
VI. Group PDSA Pre-intervention Cycle (Cycle #1)
a. PLAN Identify project, metrics, and target (Group PQI Meeting #1)
- Select a topic area in which your practice group would like to see your practice improve, and within it, decide on a systems-based challenge that is relevant to your practice. The purpose of PQI is to address and improve real issues in your practice, so performance topics that do not present challenges or perceived gaps in practice are not appropriate as subjects for PQI projects.
- Decide specifically what your practice group will measure to assess current performance and future improvement and create a data collection form to record the measurements (if one does not already exist).
- Determine an appropriate desired project target that will help in your evaluation after the project has been completed.
- Determine a prediction of what the baseline measurement result will be to help align perception with reality during data analysis.
b. DO Data collection (Occurs between meetings)
- Make a baseline measurement in an appropriate number of cases drawn in an unbiased manner.
c. STUDY Data Analysis (Group PQI Meeting #2)
- Your practice group comes together to review and analyze the baseline data collected to date, discuss the implications of the results for the practice, and determine the perceived root causes for not meeting the performance measurement target/goal. Compare the results with the predicted measurement results.
d. ACT Action Plan (Group PQI Meeting #3)
VII. Post-improvement Plan PDSA Cycle (Cycle #2)
After establishing baseline results, conduct a second PDSA cycle to assess the impact of the plan on the baseline measurement.
- If you have not met your measure target, devise an improvement plan addressing the root causes, as well as a process for plan implementation. Proceed to PDSA Cycle #2.
- If you have met your measure target, terminate this project, select another topic, and proceed with a new project.
a. PLAN Implement the improvement plan and confirm your data collection process.
b. DO Collect re-measurement data.
c. STUDY Analyze re-measurement data.
d. ACT Project decision point (Group PQI Meeting #4)
VIII. Group Project Template
ABTS GROUP PQI PROJECT TEMPLATE: To assist group participants in following and documenting the required process, the ABTS has composed an optional digital template, which may be used in completing PQI projects.
- Analyze the post-improvement plan re-measurement data and determine whether your group has met its performance goal.
- If so, select another project to start as appropriate, while maintaining the gains made in the initial project. For the purposes of MOC, the requirements have been met at this point. For those interested in continuing the PQI process, the steps might be continued as desired to maintain or further improve outcomes.
- If the goal has not been met, continue with the initial project and repeat PDSA cycle(s) as necessary to attempt to reach the desired goal. For the purposes of MOC, the requirements have been met at this point.
- When you complete your project, you must prepare a short paragraph stating how the project might positively impact your practice and/or your patients. Example:“By appropriately adjusting the schedule of our outpatient clinic to reflect real times spent with the patient and real waiting times for patients yet to be seen, we were able to reduce the number of patients with excessively long waits and improve satisfaction with the care.”
- Fulfilling the MOC PQI requirements: Each Group PQI participant must complete one PQI project in the previous 2 years as a part of each MOC 5-year milestone. Do not forget that each group participant must record and attest the PQI project with the ABTS.