2022 Quality Summit ePosters (Non-CE) - LAAO Registry-1. Developing a System Standard for Program Readiness and Continuous Quality Improvement

1. Developing a System Standard for Program Readiness and Continuous Quality Improvement

Pdf Summary

This document outlines the development and implementation of a Left Atrial Appendage (LAA) closure device program at Indiana University Health (IUH) hospitals. The program was initiated in 2016 at the flagship hospital and subsequently launched at two additional hospitals. To ensure standardization and alignment with the IU CV Institute, a program standards document was created.<br /><br />The document includes three columns that specify requirements from the National Coverage Determination (NCD), recommendations from expert consensus documents, and the new IUH standards. It is divided into three main categories: Infrastructure, Process, and Outcomes.<br /><br />To support continuous quality improvement, quarterly multidisciplinary performance improvement teams were established. Additionally, shared decision-making auto-text templates were developed for both interventionalists and non-interventionalists. The System Quality team collaborated with Revenue Cycle to ensure compliance with NCD requirements.<br /><br />The implementation of the auto-text template tracking resulted in improved compliance with shared decision-making documentation at Hospital A (from 0% in 2020 to 91% in 2022 YTD) and Hospital B (from 64% in 2020 to 100% in 2022 YTD). However, Hospital C has seen little improvement in compliance thus far.<br /><br />The document has allowed IUH to standardize patient care across the system and has been a valuable resource during staffing changes. It provides a concise framework for ongoing program readiness and compliance with National Coverage Determination.<br /><br />Overall, the IUH LAA program standards document aims to provide hospital leaders and physicians with a clear resource to maintain program readiness, facilitate transparent discussions, and ensure compliance with standards.

Keywords

Left Atrial Appendage closure device program

Indiana University Health hospitals

program standards document

National Coverage Determination

Infrastructure

Process

Outcomes

continuous quality improvement

compliance

program readiness