VQI/PSO Fellow Training Program Update & Milestone Timeline

VQI/PSO Fellow in Training A Pilot program Next Generation VQI Member Alliance Gary W Lemmon MD,FACS Associate Medical Director- VQI, Quality Annual Retreat Update

Name: Affiliation: Contact Information: Representation: Gary Lemmon, M.D., FACS Chairperson Associate Medical Director VQI, glemmon@svspso.org PSO Staff SVS PSO FIT Committee Members Quality Bridgitte Smith, M.D. Co-Chairperson University of Utah Hospitals & Clinics Bridgitte.smith@hsc.Utah.edu APDVS Ashley Gutwein, M.D. Indiana University Health System asgutwei@iu.edu 0-5 Resident Ashley Vavra, M.D. Northwestern Memorial Hospital Ashley.Vavra@nm.org Governing Council SVS PSO FIT Committee Members Beau Hawkins, M.D. OU Medical Center Beau-Hawkins@ouhsc.edu SCAI Betsy Wymer, DNP, RN, RN-BC SVS PSO Director of Quality bwymer@svspso.org PSO Staff Dmitriy Feldman, M.D. Weill Cornell University Medical Center dnf9001@med.cornell.edu SVM Faisal Aziz, M.D. Penn State Health Milton S. Hershey Medical Center Faziz@pennstatehealth.psu.edu Governing Council Gabriela Velazquez, M.D. Wake Forest University Baptist Health Medical Center gvelazqu@wakehealth.edu APDVS Jeff Indes, M.D. Montefiore Medical Center jindes@montefiore.org Governing Council Jens Eldrup-Jorgensen, M.D. SVS PSO Medical Director Tufts University School of Medicine jjorgensen@svspso.org PSO Staff Jim Wadzinski Deputy Executive Director SVS jwadzinski@svspso.org PSO Staff Mina Boutrous, M.D. University of Connecticut Health Center Boutrous@uchc.edu VQI DE

Trainee Milestone Timeline Quality Improvement Checklist Level 1 Introduction Level 2 Acquire Knowledge Level 3 Familiarity with VQI Level 4 Participates Level 5 Leads VQI-Web Portal info (members only login) Mentor led review of variables/definitions LTFU parameters and mandatory fields Local Data Manager introduction Review of local data/QI with Mentor and DM Knowledge of Quality Charter build Regional meeting prep call (ad hoc) Existing Quality Charters and QI projects (website) Demonstrate skills for use of Registry data to develop QI project Initiate Quality Charter or QI project Publication with VQI data (minor role) National QI at center/regional level Presents QI/QC at regional/national meeting Publication with VQI data (major role) Participate in Quality Charter build at local/regional level Comments: VQI web Portal info includes Why Should I Join the VQI ; 2021 Annual Report; VQI: Past, Present and Future ; AHRQ PSO guidelines; Members Only info topics

Trainee Milestone Timeline Patient Safety Checklist Level 1 Level 2 Level 3 Level 4 Level 5 Introduction Acquire Knowledge Familiarity with PSO Participates Leads PSO Organizational Chart Pathways website and Analytic Engine Reports Audible bleeding: RAC introduction Interpret Registry reports for Quality Improvement Review existing RAC projects GC meeting attendance (ad hoc) Attend Regional Study Group Present comparative data at Regional Study Group SQUIRE 2.0 guidelines and RAC requirements for research RAC journal club Regional Project for Venous or Arterial RAC- new Join existing RAC project-analysis Abstract submission for VQI@VAM Podium presentation of RAC research RAC research publication (major role) Comments:

Scholarship Eligibility for Tier 2 progression GC oversight and approval subcommittee Review process of FIT work products Eligible work products include: a. Poster abstract and presentation at VQI@VAM with FIT direction b. QI project presentation at national meeting with FIT involvement c. Manuscript publication using VQI data with FIT involvement d. RAC research submission e. FIT directed Quality Charter

Policy on FIT Data Use with PSO Guardrails To maintain consistency with current PSO restrictions and AHRQ guidelines, we (PSO) have adopted the following policy: The ideal scenario for mentor/mentee matching will be for both individuals to come from the same institution. We believe that direct oversight and the need/ability to review identifiable data will be key to initiating successful Quality Improvement projects. We do, however, envision scenarios where the mentor and mentee may be from different institutions. In this case, we will have to limit access to data, based both on Patient Safety and RAC regulations. AHRQ Patient Safety Regulations will prohibit the viewing of identifiable information from another institution, so work will be limited to research using deidentified Blinded Data Sets. For the research project, the topic will need to be based on a registry that is subscribed to by both the Mentor s Institution, as well as the Mentee s Institution. The proposal will need to be submitted to the RAC, which will teach the Trainee how to create and submit a research proposal and receive feedback from the RAC. Upon acceptance, both the Mentor and Mentee will have to sign the data use agreement, which is part of the standard RAC process.