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The IAC Standards and Guidelines
for Cardiovascular Catheterization Accreditation

 

Click here for a printer-friendly PDF of the Cardiovascular Catheterization Standards

Part C:
Quality Improvement

Section 3C: Quality Improvement Meetings

STANDARD – QI Meetings

 

3.1C           Quality Improvement (QI) meetings must be documented.

 

3.1.1C            The facility must have a minimum of two QI meetings per year, one of which is to review the results of the QI analyses and any additional QI-related topics.


3.1.1.1C             test appropriateness;

 

3.1.1.2C             safety and procedural outcomes;

 

3.1.1.3C             interpretive quality review;


3.1.1.4C             report completeness and timeliness; and


3.1.1.5C             other related topics.


 

(See Guidelines below for further recommendations.)

 

3.1.2C            All significant complications must be reviewed during these meetings.

 

3.1.2.1C             Procedure outcomes, including success rates and complications, should be documented and recorded. Data acquired from the cardiovascular catheterization facility QI process should be used to benchmark the complication rates and outcomes of both individual practitioners and the overall cardiovascular catheterization facility.

 

3.1.2.2C             Given the often poorly defined relationship between case volumes and outcomes, a more appropriate measure is to ensure that all major complications are reviewed by the QI committee and handled as described in the previous sections.

 

3.1.2.3C             Complications and any identifiable root cause(s) and corrective action(s) must be reviewed and documented in efforts to improve future outcomes. Complications should be tracked and recorded to allow for trend changes to be documented and addressed.

 

3.1.2.4C             All relevant staff must participate in at least one meeting per year. All staff are responsible for the content discussed during the QI meetings. Therefore, every attempt should be made to either attend in person, via web conference or teleconference. If unable to attend one of the two biannual meetings, the staff member is required to review the meeting minutes and document their attendance with one of the following: Medical Director, Nurse Manager, Technical Manager and/or an appointed QI Committee member.

 

3.2C           Morbidity and Mortality (M&M) conferences must be documented.

 

3.2.1C            The Medical Director and medical staff must attend at least one M&M conference related to cardiovascular catheterization procedures per quarter.

 

 

 

 

 

Section 3C: Quality Improvement Meetings
Guidelines

 

3.1.1C    A QI Program should be in place to assess and improve the administrative quality of the facility’s operation. Administrative areas that may be assessed include, but not limited to:

 

·         scheduling back logs;

·         patient wait times;

·         accuracy of patient information during scheduling;

·         completeness of documentation;

·         time from completion of procedure to signature and distribution of final report;

·         patient satisfaction and feedback;

·         referring physician satisfaction and feedback; and

·         patient education - on individual risk factors, smoking cessation, signs and symptoms of heart arrhythmia, cardiovascular accident, stroke or myocardial infarction and calling 911, importance of follow-up after discharge, review of discharge medications including importance of adherence to antithrombotic therapy.