Southern California Vascular Outcomes Improvement Collaborative
l. Mission Statement
The Southern California Vascular Outcomes Improvement Collaborative (SoCal VOICe) is a voluntary, cooperative group of clinicians, nurses, hospital administrators and research personnel organized to improve the care of patients with vascular disease. By collecting and exchanging information, the group strives to continuously improve the quality, safety, effectiveness and cost of caring for patients with vascular disease.
Physicians and hospitals in Southern California performing any of the vascular procedures recorded by SoCal VOICe are eligible for membership. A majority vote of the Executive Committee is required to approve membership of new physicians or hospitals. Membership requires that the member hospital and physicians follow the policies and procedures established by SoCal VOICe (see Section VII). A physician, physician group or hospital which is approved for membership is hereinafter referred to as a “SoCal VOICe Member”. All physicians who perform procedures recorded by SoCal VOICe within a member hospital or physician group are considered part of SoCal VOICe.
III. Patient Safety Organization
SoCal VOICe is an unincorporated association of physicians and hospitals that use the Society for Vascular Surgery Patient Safety Organization (SVS PSO) as the vehicle for quality improvement and the M2S, Inc. Clinical Pathways product for data collection and quality report generation. Contracts are required between members and the SVS PSO and M2S Inc. The Southern California Vascular Surgery Society (SCVSS), is the fiduciary agent for SoCal VOICe. SVS PSO is a Patient Safety Organization, as defined by The Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41), implemented to protect the confidentiality of all data and resulting patient safety work product. SVS PSO is a limited liability company established by the Society for Vascular Surgery (SVS). M2S, Inc. provides web-based services to SVS PSO and thus to SoCal VOICe Members. Under the relevant agreements with each member, SVS PSO performs regional data management services for members, as requested by the SoCal VOICe Quality Committee.Each SoCal VOICe Member must have contracts with SVS PSO and M2S Inc. that affirm adherence to the SoCal VOICe Bylaws. In addition, the Executive Committee may establish an annual fee for SoCal VOICe Members to fund semiannual meetings and SoCal VOICe staff, which is paid to the SCVSS.
IV. Committees and Staff
1) Executive Committee:
The business of the SoCal VOICe shall be managed by or under the direction of an Executive Committee, which may exercise all the powers of SoCal VOICe except as otherwise determined by two-thirds of the members of SoCal VOICe. The Executive Committee conducts the business of the SoCal VOICe and makes all decisions on behalf of SoCal VOICe, including oversight of budgets, contracts, publications and relationships with outside parties, requests for membership, and the general direction of the association. In the event of a vacancy in the Executive Committee, the remaining members of the Executive Committee may exercise the powers of the full Executive Committee until the vacancy is filled. The Executive Committee may designate other committees as necessary to conduct the business of SoCal VOICe. The Executive Committee is chaired by the Medical Director who also represents SoCal VOICe on the SVS PSO Governing Council. The SoCal VOICe Executive Committee consists of one representative appointed by each SoCal VOICe hospital or physician group of three or more practitioners, as well as the Medical Director. All are voting members of the Committee. The Executive Committee may meet in person, or by conference call or email. Meetings may be called by the Medical Director, or at the request of any other two members of the Executive Committee. The Executive Committee oversees the interaction of SoCal VOICe with the SCVSS. It approves research studies and publications as recommended by the Quality Committee, relationships with outside parties, requests for membership, de-identified data distribution for research or sale to commercial entities and the general direction of the SoCal VOICe.
A quorum of the Executive Committee which consists of representatives of at least two-thirds of the eligible SoCal VOICe hospital and physician groups is necessary to conduct business. A majority vote of the members present at a meeting at which a quorum exists is required to pass resolutions. In the event that an Executive Committee member cannot attend a meeting, the hospital or physician group may designate an alternate, who shall have full voting rights. Minutes of the Executive Committee meetings are distributed electronically or via the SCVSS website to all physician members of the SoCal VOICe.
2) Quality Committee:
The SoCal VOICe Quality Committee consists of members of SoCal VOICe, epidemiologists, analysts, and administrative personnel appointed by the SoCal VOICe Executive Committee. The Chair of the Quality Committee is appointed by the Executive Committee and is the representative of SoCal VOICe on the SVS PSO Quality Committee. The SoCal VOICe Quality Committee is responsible for reviewing and offering recommendations to the Executive Committee concerning all patient safety work product including analyses, reports, benchmarking and risk adjustment of SoCal VOICe regional data performed by the SVS PSO. The Quality Committee through the Chair represents the interests of all SoCal VOICe Members to the SVS PSO, and oversees all SVS PSO quality improvement activities involving the SoCal VOICe region. Members of the SoCal VOICe Quality Committee must sign SVS PSO Confidentiality Agreements regarding PSO regulations related to confidentiality of patient identified data.
a) Medical Director is a vascular surgeon nominated by the Executive Committee and elected by a majority vote of the full membership of the Executive Committee to a three year renewable term. The Medical Director chairs the Executive Committee, prepares the agenda for SoCal VOICe meetings, prepares an annual budget and is responsible for the overall operations of the SoCal VOICe between meetings of the Executive Committee.
b) Staff Members may be hired by the Executive Committee to meet organizational and analytical needs of SoCal VOICe. Staff members are selected by the Executive Committee and their percentage effort and associated salary are set by the Executive Committee, consistent with the annual budget. SoCal VOICe Staff may include but are not restricted to:
i. Project Manager, who is responsible for day-to-day operation of the SoCal VOICe under the supervision of the Medical Director, including but not limited to support to members regarding web-based data submission and report generation, as well as preparing for SoCal VOICe meetings, coordinating quality improvement activities and all other operational functions of the group.
ii. Epidemiologist, who is responsible for oversight of the analytic and statistical functions of the group.
iii. Statistician, who is responsible for the analyses of data necessary to conduct quality improvement activities.
VI. Shared Registry Data Ownership
Each SoCal VOICe Member owns the data that it submits to the SoCal VOICe registry via the SVS PSO, and is entitled to specify and control the use of its data in the manner set forth in the SVS PSO Contract. Thus, any use of a SoCal VOICe Member data by the SoCal VOICe for purposes other than quality improvement research or any of the standard quality assurance functions performed by the SoCal VOICe shall require the prior consent of the SoCal VOICe Member, in the manner set forth in the SoCal VOICe Member Contract.
The following principles guide the function of the SoCal VOICe and must be adhered to by all members.
1) All activities of the SoCal VOICe must be consistent with the mission statement above. All data reports that compare physicians or hospitals must be anonymous.
2) Each physician member must submit data for all consecutive procedures that are recorded by SoCal VOICe and must agree to submit office claims data on a periodic basis to allow an audit to ensure accurate and complete data entry.
3) Each SoCal VOICe Member agrees to submit ICD-9 based claims data on a periodic basis to allow an audit to ensure accurate and complete data entry.
4) Each physician member must submit complete data forms, including all elements of the SoCal VOICe registry for all eligible procedures, using a web-based system approved by the SoCal VOICe, including follow-up data at one year, or other time points established by the SoCal VOICe.
5) Each SoCal VOICe Member agrees that comparative data can never be used for competitive marketing. SoCal VOICe Members own their own data, and can publish such data with the indication that it has been audited by the SoCal VOICe. However, they may not publish data provided in benchmarking reports that compares their hospital or practice with other groups in the SoCal VOICe.
6) Each SoCal VOICe Member must agree to follow the confidentiality rules of the Patient Safety Act which is designed to prevent the disclosure of any patient identifiable information, as well as any hospital or physician identifiable information. Further, each SoCal VOICe Member agrees to follow all regulations contained within the Hospital Insurance Portability and Accountability Act (HIPAA) and the Patient Safety Quality Improvement Act (PSQIA).
7) Failure to adhere to these policies may result in loss of membership in SoCal VOICe for an individual physician, physician group or hospital, if so determined by a majority vote of the Executive Committee.
Analyses will be regularly performed by SoCal VOICe to provide feedback to member hospitals and physicians for purposes of quality improvement. These may yield useful information that could benefit the medical community at large, and warrant scientific publication or presentation. Proposals for specific research projects using shared regional data may be made by any SoCal VOICe Member, and shall be considered by the Quality Committee. The Quality Committee will consider and make recommendations concerning proposed research projects to the Executive Committee. If approved by the Executive Committee such projects may proceed. All SoCal VOICe Members conducting such research agree to abide by all SoCal VOICe confidentiality rules, all HIPAA regulations, and all PSQIA regulations that are relevant to protecting the privacy of both patients and the member hospitals and physicians, none of whom shall be identified in any publication. All resulting publications and presentations shall be authored by the specific participating individuals from SoCal VOICe and carry the author byline “on behalf of the Southern California Vascular Outcomes Improvement Collaborative (SoCal VOICe).” Each participant in such research must sign a statement that attests to these agreements.
Bylaws may be amended by a vote of two-thirds of the full membership of the Executive Committee, provided that such amendments are circulated electronically and on the SCVSS website at least 30 days prior to their consideration. Any amendments published on the SCVSS website shall be deemed incorporated herein by reference.
(Version 1.0, January 17, 2012)
(Governing Council Approved 2.3.2012)