Florida-Georgia Vascular Study Group (FGVSG) Bylaws
l. Mission Statement
The Florida-Georgia Vascular Study Group (FGVSG) is a voluntary, cooperative group of clinicians, 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.
Hospitals and physicians performing any of the vascular procedures recorded by FGVSG are eligible for membership if they are located Florida and Georgia. Membership requires that the member hospital or physician follow the policies and procedures established by FGVSG (see Section VI). Hospitals act as the contracting agent for membership in FGVSG, such that physicians who perform vascular procedures in that hospital are eligible to participate. A majority vote of the FGVSG Executive Committee is required to approve membership of new hospitals. A hospital which is approved for membership is hereinafter referred to as a “FGVSG Member.”
III. Patient Safety Organization
The FGVSG is an unincorporated association of member hospitals and physicians that use the Society for Vascular Surgery® Patient Safety Organization (SVS PSO) as the vehicle for quality improvement and the M2S, Inc. Pathways product for data collection and quality report generation. Contracts are required between member hospitals and the SVS PSO, and M2S, Inc. The 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 created for the purpose of satisfying FGVSG’s desire for a patient safety organization by the Society for Vascular Surgery® (SVS). M2S, Inc. provides web-based services to SVS PSO related to the FGVSG registry, under an administrative services agreement. Under the relevant agreements with each member hospital, SVS PSO will perform common data management services for member institutions, as determined by the FGVSG Quality Committee of the SVS PSO.
Each member hospital must have contracts with SVS PSO, and M2S, Inc., which affirms adherence to the FGVSG Bylaws. The form of the Hospital Contracts with SVS PSO, and M2S, Inc., must be approved by the FGVSG Executive Committee, including the costs for SVS PSO, and M2S. The Hospital Contracts shall include annual charges, based on hospital procedure volume or number of participating physicians, to be paid to SVS PSO and M2S for web-based data collection, data management and report generation. In addition, the Executive Committee may establish an annual fee for FGVSG hospitals to fund semiannual meetings and FGVSG staff.
IV. Committees and Staff
1) Executive Committee
The business of the FGVSG shall be managed by or under the direction of an Executive Committee, which may exercise all the powers of the FGVSG except as otherwise determined by two-thirds of the FGVSG Member hospitals. The Executive Committee conducts the business of the FGVSG and makes all decisions on behalf of the FGVSG, including oversight of budgets, contracts, publications, 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 FGVSG.
The FGVSG Executive Committee consists of one representative appointed by each FGVSG Member hospital, as well as the Medical Director, Project Manager and Epidemiologist, all of whom 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 FGVSG with the SVS PSO, and M2S, Inc., including costs and contractual details for FGVSG Member hospital participation in the SVS PSO. It approves research studies and publications, relationships with outside parties, requests for membership, de-identified data distribution for research or sale to commercial entities and the general direction of the FGVSG.
A quorum of the Executive Committee consists of representatives of at least two-thirds of the FGVSG Member hospitals, which 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 may designate an alternate, who shall have full voting rights. Minutes of the Executive Committee meetings are distributed electronically or via the FGVSG website to all hospital and physician members of the FGVSG.
2) Quality Committee
The FGVSG Quality Committee consists of physicians, analysts, and administrative personnel appointed by the FGVSG Executive Committee to the FGVSG Quality Committee of the SVS PSO. The FGVSG Quality Committee is responsible for all decision making concerning patient safety work product production using FGVSG regional data within the SVS PSO, including types of analyses, reports, benchmarking, and risk adjustment to be conducted by the SVS PSO. The Quality Committee represents the interests of all FGVSG member hospitals and physicians on the SVS PSO, and oversees all SVS PSO quality improvement activities for the FGVSG region. Members of the FGVSG Quality Committee must sign SVS PSO Confidentiality Agreements to abide by PSO regulations regarding confidentiality of patient identified data.
a) The Medical Director is a physician 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 FGVSG meetings, prepares an annual budget and is responsible for the overall operations of the FGVSG between meetings of the Executive Committee.
b) Staff Members may be hired by the Executive Committee to meet organizational and analytical needs of FGVSG. 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. FGVSG Staff may include but are not restricted to:
i. A Project Manager, who is responsible for day-to-day operation of the FGVSG under the supervision of the Medical Director, including but not limited to support to member hospitals regarding web-based data submission and report generation, as well as preparing for FGVSG meetings, coordinating quality improvement activities and all other operational functions of the group.
ii. An Epidemiologist, who is responsible for oversight of the analytic and statistical functions of the group.
iii. A Statistician, who is responsible for the analyses of data necessary to conduct quality improvement activities.
V. Shared Registry Data Ownership
Each hospital owns the data that it submits to the FGVSG registry via the SVS PSO, and is entitled to specify and control the use of its data in the manner set forth in the Hospital Contract. Thus, any use of a hospital’s data by the FGVSG for purposes other than quality improvement research or any of the standard quality assurance functions performed by the FGVSG shall require the prior consent of the hospital, in the manner set forth in the Hospital Contract.
The following principles guide the function of the FGVSG and must be adhered to by all members.
1) All activities of the FGVSG must be consistent with the mission statement above. All data reports that compare physicians or hospitals must be anonymous, unless identification of specific hospitals or physicians is unanimously approved by the involved hospitals or physicians. Any reports that identify hospitals or physicians are considered quality assurance documents. All members of the FGVSG agree to keep such information strictly confidential.
2) Each physician member must submit data for all consecutive procedures that are recorded by FGVSG 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 member hospital 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 member hospital and physician must submit complete data forms, including all elements of the FGVSG registry for all eligible procedures, using a web-based system approved by the FGVSG, including follow-up data at one year, or other time points established by the FGVSG.
5) Each member hospital and physician agrees that comparative data can never be used for competitive marketing. Hospitals and physicians own their own data, and can publish such data with the indication that it has been audited by the FGVSG. However, they may not publish data provided in benchmarking reports that compares their hospital or practice with other groups in the FGVSG.
Each hospital and physician member must agree to follow the FGVSG Confidentiality Manual which is available on the FGVSG website (www.vascularweb.org/FGVSG
), and is designed to prevent the disclosure of any patient identifiable information, as well as any hospital or physician identifiable information. Further, each FGVSG hospital and physician member agrees to follow all regulations contained within the Hospital Insurance Portability and Accountability Act (HIPAA) and the Patient Safety Quality Improvement Act (PSQIA).
Failure to adhere to these policies may result in loss of membership in FGVSG for a hospital or physician, if so determined by a majority vote of the Executive Committee.
Analyses will be regularly performed by the FGVSG to provide feedback to member hospitals and physicians for purposes of quality improvement within the SVS PSO. 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 FGVSG Member hospital or physician, and shall be considered by the Executive Committee. If approved by the Executive Committee such projects may proceed. All FGVSG Members conducting such research agree to abide by all FGVSG 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 the FGVSG and carry the author byline “on behalf of the Florida-Georgia Vascular Study Group.” 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 FGVSG website at least 30 days prior to their consideration. Any amendments published on the FGVSG website shall be deemed incorporated herein by reference.