Abstract
Co-authors: Kelly Nelson, RN – Project Manager, Registry Partners; Samantha Hillman, MS – Registry Solutions Advisor, Registry Partners; Terri Jamison, BSN RN – Sr. Program Manager for Structural Heart, Houston Methodist Hospital; Maria Victoria Tiu, MSN, RN, CPHQ – Manager Quality External Reporting, Houston Methodist Hospital
Kelly Nelson, RN – Project Manager, Registry Partners; Samantha Hillman, MS – Registry Solutions Advisor, Registry Partners; Terri Jamison, BSN RN – Sr. Program Manager for Structural Heart, Houston Methodist Hospital; Maria Victoria Tiu, MSN, RN, CPHQ – Manager Quality External Reporting, Houston Methodist Hospital Problem Statement or Scientific Question: The need for increased compliance in completion of both pre-procedure and 30-day follow up Kansas City Cardiomyopathy Questionnaire (KCCQ) for all transcatheter valve procedures.
Background/Project Intent: In November 2023, the National Cardiovascular Data Registry (NCDR®) released an outlier report regarding STS/ACC TVT Registry™ Metric 316, Patients with Acceptable Quality of Life Outcome at 30 Days Based on KCCQ Summary. Using a drill-down method, data revealed that 33% of patients did not complete the pre-procedure KCCQ within 90 days of the procedure, and 28% did not complete the KCCQ on the 30-day follow up. This result impacted our site's ability to meet the 75th percentile for this metric, leading to a process improvement initiative to capture both pre-procedure and follow up KCCQs for all transcatheter procedures.
Methodology: ● Formed a team consisting of Quality External Reporting Manager, Continuous Quality Improvement Specialist (CQIS), TVT Coordinator, clinic designated staff, and Registry Partners Cardiac Registry Consultant ● Team reviewed metric outlier report using Patient Level Drill Down feature to identify and validate missing pre-procedure and 30-day follow up KCCQs ● Team reviewed all available hospital-wide software systems utilized within the patient-care process to determine where KCCQ completion could be captured ● Determined to utilize the surgical scheduling database to monitor pre-procedure KCCQ completion once the patient has been scheduled ● Weekly report developed and shared by TVT Coordinator for valve team to capture all missing pre-procedure KCCQs prior to patient’s scheduled inpatient/outpatient procedure ● Developed an Excel log to track missing 30-day follow up KCCQs allowing TVT Coordinator to communicate with valve clinic to coordinate with patients for follow up KCCQ completion ● TVT Coordinator and CQIS update the Excel log when missing 30-day follow up KCCQ is complete and entered in the EMR; Registry Partners Cardiac Registry Consultant updates missing KCCQ responses in registry data collection tool ● Registry Partners Cardiac Registry Consultant to submit data and review dashboard metrics on a bi-weekly basis ● The team referenced above meets to review all dashboard metrics prior to quarterly TVT Valve Committee meetings
Results: Data was reviewed using the NCDR STS/ACC TVT Registry Dashboard. Performance for Metric 316 for 3Q2023 38.9% (n=18 patients for quarter). Data showed that 33% of patients did not complete the pre-procedure KCCQ within 90 days of the procedure, and 28% did not complete the KCCQ on the 30-day follow-up. Following the initiation of this process improvement initiative in December 2024, 4Q2023 Performance trend increased to 50.0% (n=16 patients per quarter), with N=1 missing pre-procedure KCCQ and N=3 missing KCCQ on 30-day follow up. For 1Q2024 the Performance trend further increased to 55.6% (n=18 patients for quarter) overall, with N=0 missing KCCQ pre-procedure, and N=4 missing 30-day follow up KCCQ.
Value Proposition: Utilizing the KCCQ pre and post-procedure can serve as a valuable tool to determine if a valve procedure has been successful in improving a patient’s daily activity level and quality of life. This benefits society as a whole with better overall community health and reduced spending on medications and hospitalizations. Providers benefit from consistent completion of the KCCQ pre and post-procedure as it provides insight to the patient’s overall functional status, allowing for customization of patient-centered care. It also provides feedback as to the overall success of these procedures for their patient population.
Conclusions: The data reflects how a designated, team-approach enabled this facility to improve overall compliance of KCCQ completion pre and post-procedure. The implementation of a similar process in other institutions could lead to further improvements in Metric 316, leading to increased insights to the success of transcatheter valve procedures over time. Current consideration at this facility includes the further development of the template within the surgical scheduling database to ensure that all pre-procedure requisites are completed with the appropriate timeframes for each scheduled patient. A subsequent initiative that could be carried out in follow up to this compliance process initiative would be to then focus on the KCCQ score performance itself.
References: N/A
Kelly Nelson, RN – Project Manager, Registry Partners; Samantha Hillman, MS – Registry Solutions Advisor, Registry Partners; Terri Jamison, BSN RN – Sr. Program Manager for Structural Heart, Houston Methodist Hospital; Maria Victoria Tiu, MSN, RN, CPHQ – Manager Quality External Reporting, Houston Methodist Hospital Problem Statement or Scientific Question: The need for increased compliance in completion of both pre-procedure and 30-day follow up Kansas City Cardiomyopathy Questionnaire (KCCQ) for all transcatheter valve procedures.
Background/Project Intent: In November 2023, the National Cardiovascular Data Registry (NCDR®) released an outlier report regarding STS/ACC TVT Registry™ Metric 316, Patients with Acceptable Quality of Life Outcome at 30 Days Based on KCCQ Summary. Using a drill-down method, data revealed that 33% of patients did not complete the pre-procedure KCCQ within 90 days of the procedure, and 28% did not complete the KCCQ on the 30-day follow up. This result impacted our site's ability to meet the 75th percentile for this metric, leading to a process improvement initiative to capture both pre-procedure and follow up KCCQs for all transcatheter procedures.
Methodology: ● Formed a team consisting of Quality External Reporting Manager, Continuous Quality Improvement Specialist (CQIS), TVT Coordinator, clinic designated staff, and Registry Partners Cardiac Registry Consultant ● Team reviewed metric outlier report using Patient Level Drill Down feature to identify and validate missing pre-procedure and 30-day follow up KCCQs ● Team reviewed all available hospital-wide software systems utilized within the patient-care process to determine where KCCQ completion could be captured ● Determined to utilize the surgical scheduling database to monitor pre-procedure KCCQ completion once the patient has been scheduled ● Weekly report developed and shared by TVT Coordinator for valve team to capture all missing pre-procedure KCCQs prior to patient’s scheduled inpatient/outpatient procedure ● Developed an Excel log to track missing 30-day follow up KCCQs allowing TVT Coordinator to communicate with valve clinic to coordinate with patients for follow up KCCQ completion ● TVT Coordinator and CQIS update the Excel log when missing 30-day follow up KCCQ is complete and entered in the EMR; Registry Partners Cardiac Registry Consultant updates missing KCCQ responses in registry data collection tool ● Registry Partners Cardiac Registry Consultant to submit data and review dashboard metrics on a bi-weekly basis ● The team referenced above meets to review all dashboard metrics prior to quarterly TVT Valve Committee meetings
Results: Data was reviewed using the NCDR STS/ACC TVT Registry Dashboard. Performance for Metric 316 for 3Q2023 38.9% (n=18 patients for quarter). Data showed that 33% of patients did not complete the pre-procedure KCCQ within 90 days of the procedure, and 28% did not complete the KCCQ on the 30-day follow-up. Following the initiation of this process improvement initiative in December 2024, 4Q2023 Performance trend increased to 50.0% (n=16 patients per quarter), with N=1 missing pre-procedure KCCQ and N=3 missing KCCQ on 30-day follow up. For 1Q2024 the Performance trend further increased to 55.6% (n=18 patients for quarter) overall, with N=0 missing KCCQ pre-procedure, and N=4 missing 30-day follow up KCCQ.
Value Proposition: Utilizing the KCCQ pre and post-procedure can serve as a valuable tool to determine if a valve procedure has been successful in improving a patient’s daily activity level and quality of life. This benefits society as a whole with better overall community health and reduced spending on medications and hospitalizations. Providers benefit from consistent completion of the KCCQ pre and post-procedure as it provides insight to the patient’s overall functional status, allowing for customization of patient-centered care. It also provides feedback as to the overall success of these procedures for their patient population.
Conclusions: The data reflects how a designated, team-approach enabled this facility to improve overall compliance of KCCQ completion pre and post-procedure. The implementation of a similar process in other institutions could lead to further improvements in Metric 316, leading to increased insights to the success of transcatheter valve procedures over time. Current consideration at this facility includes the further development of the template within the surgical scheduling database to ensure that all pre-procedure requisites are completed with the appropriate timeframes for each scheduled patient. A subsequent initiative that could be carried out in follow up to this compliance process initiative would be to then focus on the KCCQ score performance itself.
References: N/A
Co-authors: Kelly Nelson, RN – Project Manager, Registry Partners; Samantha Hillman, MS – Registry Solutions Advisor, Registry Partners; Terri Jamison, BSN RN – Sr. Program Manager for Structural Heart, Houston Methodist Hospital; Maria Victoria Tiu, MSN, RN, CPHQ – Manager Quality External Reporting, Houston Methodist Hospital
Kelly Nelson, RN – Project Manager, Registry Partners; Samantha Hillman, MS – Registry Solutions Advisor, Registry Partners; Terri Jamison, BSN RN – Sr. Program Manager for Structural Heart, Houston Methodist Hospital; Maria Victoria Tiu, MSN, RN, CPHQ – Manager Quality External Reporting, Houston Methodist Hospital Problem Statement or Scientific Question: The need for increased compliance in completion of both pre-procedure and 30-day follow up Kansas City Cardiomyopathy Questionnaire (KCCQ) for all transcatheter valve procedures.
Background/Project Intent: In November 2023, the National Cardiovascular Data Registry (NCDR®) released an outlier report regarding STS/ACC TVT Registry™ Metric 316, Patients with Acceptable Quality of Life Outcome at 30 Days Based on KCCQ Summary. Using a drill-down method, data revealed that 33% of patients did not complete the pre-procedure KCCQ within 90 days of the procedure, and 28% did not complete the KCCQ on the 30-day follow up. This result impacted our site's ability to meet the 75th percentile for this metric, leading to a process improvement initiative to capture both pre-procedure and follow up KCCQs for all transcatheter procedures.
Methodology: ● Formed a team consisting of Quality External Reporting Manager, Continuous Quality Improvement Specialist (CQIS), TVT Coordinator, clinic designated staff, and Registry Partners Cardiac Registry Consultant ● Team reviewed metric outlier report using Patient Level Drill Down feature to identify and validate missing pre-procedure and 30-day follow up KCCQs ● Team reviewed all available hospital-wide software systems utilized within the patient-care process to determine where KCCQ completion could be captured ● Determined to utilize the surgical scheduling database to monitor pre-procedure KCCQ completion once the patient has been scheduled ● Weekly report developed and shared by TVT Coordinator for valve team to capture all missing pre-procedure KCCQs prior to patient’s scheduled inpatient/outpatient procedure ● Developed an Excel log to track missing 30-day follow up KCCQs allowing TVT Coordinator to communicate with valve clinic to coordinate with patients for follow up KCCQ completion ● TVT Coordinator and CQIS update the Excel log when missing 30-day follow up KCCQ is complete and entered in the EMR; Registry Partners Cardiac Registry Consultant updates missing KCCQ responses in registry data collection tool ● Registry Partners Cardiac Registry Consultant to submit data and review dashboard metrics on a bi-weekly basis ● The team referenced above meets to review all dashboard metrics prior to quarterly TVT Valve Committee meetings
Results: Data was reviewed using the NCDR STS/ACC TVT Registry Dashboard. Performance for Metric 316 for 3Q2023 38.9% (n=18 patients for quarter). Data showed that 33% of patients did not complete the pre-procedure KCCQ within 90 days of the procedure, and 28% did not complete the KCCQ on the 30-day follow-up. Following the initiation of this process improvement initiative in December 2024, 4Q2023 Performance trend increased to 50.0% (n=16 patients per quarter), with N=1 missing pre-procedure KCCQ and N=3 missing KCCQ on 30-day follow up. For 1Q2024 the Performance trend further increased to 55.6% (n=18 patients for quarter) overall, with N=0 missing KCCQ pre-procedure, and N=4 missing 30-day follow up KCCQ.
Value Proposition: Utilizing the KCCQ pre and post-procedure can serve as a valuable tool to determine if a valve procedure has been successful in improving a patient’s daily activity level and quality of life. This benefits society as a whole with better overall community health and reduced spending on medications and hospitalizations. Providers benefit from consistent completion of the KCCQ pre and post-procedure as it provides insight to the patient’s overall functional status, allowing for customization of patient-centered care. It also provides feedback as to the overall success of these procedures for their patient population.
Conclusions: The data reflects how a designated, team-approach enabled this facility to improve overall compliance of KCCQ completion pre and post-procedure. The implementation of a similar process in other institutions could lead to further improvements in Metric 316, leading to increased insights to the success of transcatheter valve procedures over time. Current consideration at this facility includes the further development of the template within the surgical scheduling database to ensure that all pre-procedure requisites are completed with the appropriate timeframes for each scheduled patient. A subsequent initiative that could be carried out in follow up to this compliance process initiative would be to then focus on the KCCQ score performance itself.
References: N/A
Kelly Nelson, RN – Project Manager, Registry Partners; Samantha Hillman, MS – Registry Solutions Advisor, Registry Partners; Terri Jamison, BSN RN – Sr. Program Manager for Structural Heart, Houston Methodist Hospital; Maria Victoria Tiu, MSN, RN, CPHQ – Manager Quality External Reporting, Houston Methodist Hospital Problem Statement or Scientific Question: The need for increased compliance in completion of both pre-procedure and 30-day follow up Kansas City Cardiomyopathy Questionnaire (KCCQ) for all transcatheter valve procedures.
Background/Project Intent: In November 2023, the National Cardiovascular Data Registry (NCDR®) released an outlier report regarding STS/ACC TVT Registry™ Metric 316, Patients with Acceptable Quality of Life Outcome at 30 Days Based on KCCQ Summary. Using a drill-down method, data revealed that 33% of patients did not complete the pre-procedure KCCQ within 90 days of the procedure, and 28% did not complete the KCCQ on the 30-day follow up. This result impacted our site's ability to meet the 75th percentile for this metric, leading to a process improvement initiative to capture both pre-procedure and follow up KCCQs for all transcatheter procedures.
Methodology: ● Formed a team consisting of Quality External Reporting Manager, Continuous Quality Improvement Specialist (CQIS), TVT Coordinator, clinic designated staff, and Registry Partners Cardiac Registry Consultant ● Team reviewed metric outlier report using Patient Level Drill Down feature to identify and validate missing pre-procedure and 30-day follow up KCCQs ● Team reviewed all available hospital-wide software systems utilized within the patient-care process to determine where KCCQ completion could be captured ● Determined to utilize the surgical scheduling database to monitor pre-procedure KCCQ completion once the patient has been scheduled ● Weekly report developed and shared by TVT Coordinator for valve team to capture all missing pre-procedure KCCQs prior to patient’s scheduled inpatient/outpatient procedure ● Developed an Excel log to track missing 30-day follow up KCCQs allowing TVT Coordinator to communicate with valve clinic to coordinate with patients for follow up KCCQ completion ● TVT Coordinator and CQIS update the Excel log when missing 30-day follow up KCCQ is complete and entered in the EMR; Registry Partners Cardiac Registry Consultant updates missing KCCQ responses in registry data collection tool ● Registry Partners Cardiac Registry Consultant to submit data and review dashboard metrics on a bi-weekly basis ● The team referenced above meets to review all dashboard metrics prior to quarterly TVT Valve Committee meetings
Results: Data was reviewed using the NCDR STS/ACC TVT Registry Dashboard. Performance for Metric 316 for 3Q2023 38.9% (n=18 patients for quarter). Data showed that 33% of patients did not complete the pre-procedure KCCQ within 90 days of the procedure, and 28% did not complete the KCCQ on the 30-day follow-up. Following the initiation of this process improvement initiative in December 2024, 4Q2023 Performance trend increased to 50.0% (n=16 patients per quarter), with N=1 missing pre-procedure KCCQ and N=3 missing KCCQ on 30-day follow up. For 1Q2024 the Performance trend further increased to 55.6% (n=18 patients for quarter) overall, with N=0 missing KCCQ pre-procedure, and N=4 missing 30-day follow up KCCQ.
Value Proposition: Utilizing the KCCQ pre and post-procedure can serve as a valuable tool to determine if a valve procedure has been successful in improving a patient’s daily activity level and quality of life. This benefits society as a whole with better overall community health and reduced spending on medications and hospitalizations. Providers benefit from consistent completion of the KCCQ pre and post-procedure as it provides insight to the patient’s overall functional status, allowing for customization of patient-centered care. It also provides feedback as to the overall success of these procedures for their patient population.
Conclusions: The data reflects how a designated, team-approach enabled this facility to improve overall compliance of KCCQ completion pre and post-procedure. The implementation of a similar process in other institutions could lead to further improvements in Metric 316, leading to increased insights to the success of transcatheter valve procedures over time. Current consideration at this facility includes the further development of the template within the surgical scheduling database to ensure that all pre-procedure requisites are completed with the appropriate timeframes for each scheduled patient. A subsequent initiative that could be carried out in follow up to this compliance process initiative would be to then focus on the KCCQ score performance itself.
References: N/A
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