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Quality Improvement Plan

COAP’s quality improvement (QI) action plan for the year 2003 includes the following four major objectives. The results of trend-analyses across the state will drive and support COAP’s efforts in providing information to hospitals and assisting them as they endeavor to achieve their QI goals. COAP will also formalize participation status in the program so that hospitals may demonstrate active participation in statewide QI efforts. COAP’s activities in support of these goals are consistent with CQIP requirements.

1. Provide meaningful (timely, valid, reliable, pertinent) information to hospitals and providers

COAP will provide periodic (quarterly, annual, cumulative) reports that include descriptive and risk-adjusted information and comparisons to national benchmarks.

2. Identify and highlight key indicators of quality for QI focus among all COAP participants with the goal of improving clinical practice across the state.

Each indicator has been selected based on the presence of a solid base of evidence to support its links to improved clinical outcomes and lower costs; its effect on large numbers of patients in the state; and the presence of wide variability in performance among hospitals. The indicators are use of arterial grafts in CABGs; early extubation post-CABG; blood transfusion in CABG patients.

3. Perform trend tracking using the information as described in 1 above.

The Management Committee will activate the continuous quality improvement system for hospitals with any process or outcome measure that is outside the 95% confidence interval of the state mean for that parameter. This process will consist of (a) notifying the site of the finding, (b) confirmation of validity of the finding, (c) a request for a site response that will outline a plan of action and a time frame for improvement, (d) MC review of the proposal in a blinded format, (e) re-measurement and review by MC after specified time interval (re-measurement is described in the Executive Summary).

4. Annually assess participation status in COAP.

1. Hospitals must make continued and full efforts to participate, in the judgment of the Management Committee. Before a hospital’s status is changed from “participating in full compliance with community QI standards,” that hospital will have opportunity to audit its data. Any action relevant to participation status must be approved by 2/3 vote of Management Committee.
2. The definition of “participating in full compliance with community QI standards ” is the following:
   1. Data completeness: at least 90% of eligible CABG and PCI cases are submitted (verified by CHARS);
   2. Data reliability: at least 90% score on inter-rater reliability tests;
   3. Data timeliness: hospital submits data for all four quarters by the annual due date;
   4. As described in 3 above, a hospital that has any process or outcome measure that is outside the 95% confidence interval of the state mean for that parameter (a) has an acceptable improvement plan in process and (b) does not exceed the threshold of persistent outliers upon re-measurement.
3. A hospital that does not meet all criteria described in 4.b is considered to be “participating in partial compliance with community QI standards.”

 

Approved by COAP Management Committee 3.19.03; revised & approved 6.18.03.