»» Good morning. It's 9.15, so I guess we'll start. I don't know how many of you, I'm Joan Michaels, I'm the Program Manager along with Carol Crone who works at STS for the TVT Registry. If this is your first time falling out from under a rock, we're the TVT team. So thank you. Thank you for hanging in there for Friday. And I hope that you have found these past few days helpful. What we tried to do was kind of do a building of a story. And the end of the day is here, and we're hoping that you're leaving with a mental physical toolkit to go back with some, not everything, not one size fits all, but some gems, some tools that you can go back and improve your program. I hope you leave with a list of contacts from other sites. We want to share information. Our phone numbers and our emails are on the app. We don't know how long the app will be up, but please know that. I think people know they could always either call or text me. I pick up the phone if I'm not doing something. I'll get back to you. Hopefully I do that in a timely manner. I don't have the answers. I send them to Kristen Young who's sitting in the room and she answers them. Kristen, raise your hand so you could. She's a team of two. Karen is not here today, but Kristen, if you talk to her, I don't have to say anything else. She gets it. She knows all the answers. But collaboration, teamwork, sharing, this is when we say hashtag Tavern Nation, we mean it. We try to help. So I hope you're going to find this session helpful, building on from what Dr. Batchelor talked about in terms of what's hot and new, what's happening. And then yesterday, Dr. Suzanne Arnold, who I'm still in awe of, because if you have never heard, I hope you were there yesterday, I don't want you to feel like you missed something. If you did miss it, you did miss something big. And if you Google her, what immediately pops up is quality of life, KCCQ, frailty. And I hope you got to meet her or at least feel her presentation yesterday that she just lives quality. And she lives, trust her when she says it is a validated tool. And I hope, we talked to many of you after that presentation that, you know, our ducks don't really need that. And we do the eyeball test and they know their patients better and they don't feel that's valuable. Please know that is so important and that is so valuable as we build ongoing TBT program to include mitral and tricuspid and continuing with aortic, not only for the baseline but for that follow-up. It was really, really scary when this whole thing started 10 years ago to think about can this work? Everybody said no, it can't. And a bunch of us were just in a recent industry meeting where the only reason why some industry folks even got involved in TAVR is because they knew it was coming, they knew it was going to fail, but they kind of had to get involved with it. So it was a surprise to them too that it was such a success. So it's because of you, it's because of your detail, it's because of your data, what you have done over the past 10 years, and I'm not just saying that. If you've been in this business you know what PCIs, covered stents, anything that came down the pike, nothing has moved as fast as TAVR. Nothing has moved as fast as what you'll be seeing in tricuspid and mitral. So I see this as sort of the second hill we're going to climb together. KCCQ with mitral and tricuspid will be critically important. So please, please, please review her slides. I hope you heard her presentation. What we're going to do today is take some of those gems and say between the two women that are up here, what can you take from what they have done and build from that? So again, one size does not fit all, but if you're a single hospital, if you're a system hospital, you'll find some ideas to take home with you, I hope. So with that, I'll first introduce Cheryl Fiedling who's my buddy I guess for 10 years. She spoke at an early, early Quality Summit meeting in D.C. And we've collaborated and worked through the years. And the theme of the day today is going to be collaboration. So I wrote a couple of things down about Cheryl. But you may or may not know, she is the Clinical Quality Lead for the whole state of Michigan. So Michigan has a very unique, sweet deal where she kind of hovers over all 30 sites within small, big, new, mature, whatever, really supporting TVT people and kind of some of the naysayers, some of the on-the-fence folks. She actually visits, personally visits once a year all 30 sites and takes the Michigan Structural Heart Initiative Consortium collaborative, you know, aggregated data and will show how you are functioning and performing compared to other programs in Michigan. And then again, sharing and learning. And I don't know if I want to say this, but I heard her say yesterday to a site who is not in Michigan. So that's what we call state creep, right? I'm not going to report you to anybody. But somebody was struggling and had a really good question. And I heard her out. I was like, well, I don't know if you should say that. And she said, call me. So she's moving out. So call her. Because she's been able to buddy the bigger sites in Michigan with the newer sites in Michigan. And the goal is same, same. Maybe same, same, but different. But same, same outcomes. And so some of the things that she'll talk today about is that's not easy. Again, it's not a template that everybody could follow. But she's done that and has done a lot of good work for the state of Michigan. Again, collaboration. My friend Holly, Holly Dalton, hails from Texas. I'm not a real fan of the Dallas Cowboys either, but we won't get into that. My dad always told me that it was Tom Landry who killed Kennedy. And I believed that for a while. But I jest. Seventeen years of clinical experience. The protege of really great TAVR folks, Ellie, I think, if you want to raise your hand, Ellie Huff's in the room. And they have such a great deal down there at Baylor Scott White. And again, collaboration. I've only known Holly for a couple of years, although she's been in the business, again, close to 20 years, and is very involved as the system program manager for the whole Baylor Scott White system. And also serves on two ACC workshops at the ACC. One is the structural heart workshop. And she's also involved in the DE&I workshop, which is becoming very popular within the company. And again, collaboration with Holly. Not knowing her as well as I know Cheryl, but knowing Ellie and know how they roll down in Texas. I don't know if she's going to show this. I don't want to do any stealing her thunder. But they did great work because they have not 30, but they have a lot of hospitals, but not 30 hospitals doing TAVR. Yet they've got all of them to kind of march in the same line. And are you going to show the mortality? Okay. No, I won't say it. But the slide she shows that we've shared with Michigan, right? Dr. Mack did a presentation at Michigan and showed the slide. I personally have permission and do so show the slide as many times as I'm asked. Because it's kind of magic. It's kind of that chill down the spine aha moment as to how they've done what they've done and why they did it. And I guess you'll tell us something about that. So who wants to go first? Okay. So welcome Cheryl Feeling from, again, great state of Michigan. »» All right. Thank you. I first want to say thank you to Joan for inviting me. And without Joan I would not be here. Joan helps me for the entire ten years and she tolerates me is probably what I should say because I have 30 sites who have questions, haven't always had 30 sites obviously, and because I go there and directly meet with their structural heart teams, like they have intense questions. Like why do you do this? Why do you do that? When are we going to do this? And I send them to Joan all the time, for the whole time. And so without her I would not be here, without her help. So I appreciate it so much. I think I was asked today because It Takes a Village is the theme. And we have built a village in Michigan and it hasn't been easy. And when I show you what we do, it isn't because, oh, it's just so easy and it happened. It wasn't easy. And we didn't have buy-in from the beginning. And we still don't have buy-in with every site. We have, let me just move forward so I don't get off track too much. But I'm going to tell you today who we are, what we do, what you can take home, and how we can help you. We have a collaborative that our mission is to improve, MISHIC is a quality improvement project designed to emphasize lifetime management, improve quality of care. It outcomes in patients who undergo structural heart procedures. We have over 130 interventional cardiologists and cardiothoracic surgeons. We're up to, you can see, about 3,500 procedures a year. This is where we started. We started with 8 sites. Now we have 30. So that's where our volume's at. If you're all, most of you don't just do one registry. And our physicians are from the PCI Registry and the STS Registry. So in Michigan those two collaboratives came together and created MISHIC. Because TAVR requires an interventionalist and a surgeon. So we said, okay, we're going to bring those two together. And we're going to have MISHIC, Michigan Structural Heart. We started out as Michigan TAVR because we only did TAVRs. But now we're MISHIC. So we're opening up for all structural heart procedures. And we're reporting on TAVR or MTRs and TMBRs. These are our sites. This is our state. We have 30 TAVR sites as I said. Twenty-two of those perform some sort of mitral procedures, 16 do TMRs. So that leaves us other six doing some small number probably of TMBRs. Some sites only do one or two a year. So that's a whole challenge there as you can imagine. So what do we do? We have all these sites and what do we do to get this collaboration? What do we do to get everybody together? What do we provide? The first thing is, I want you to know that MISHIC is voluntary. Every site in Michigan that participates in MISHIC volunteers to participate. They don't get money for it. The other CQIs as you probably heard in Michigan, they do get paid to participate in those. And I'm not going to lie and say the culture of Michigan with all of the CQIs that have been happening and PCI has been around for I think 26 years or 27, that culture has made people want to participate in MISHIC. It's voluntary. They don't get paid. They focus on sharing, mentoring, educating. And we create a culture of quality and collaboration. And the whole goal is to decrease practice variability across the state. And I don't know about your state, but when I first started this job, even when we started with TAVR in 2015, I had a lot of individual sites. Now I have a lot of systems. And so things have even changed in that way. So some of the things that we can do to collaborate and share are a lot different now than they used to be because we're going to have the expectation that systems share amongst themselves and then the systems themselves share at the Michigan level. And we're doing what we provide, we provide on a system level sometimes and a site level. So anyway, I'll talk a little bit more about that as we move along. So the meetings we have, we have TAVR and MitroFocus physician meetings. We have national speakers. Some of our recent speakers have been, well, Cabalcante, Gatta, DeVere, Bavaria, Grubbe and Dr. Arnold presented in Michigan. We have had national speakers at least two a year. And they come in and they choose a topic. And then whatever the topic is, we also ask our sites to present interesting cases. So they'll put the case up there after the talk, after the main talk they'll put the case up there. And then the whole room will talk about the case based on the topic, bicuspid, whatever it is. And then we also have coordinator meetings. We call our data abstractors coordinators because we expect them to do a lot. We expect them to do QI projects. We expect them to present. We expect them to attend meetings, participate in chart reviews. So we call them coordinators. We have those meetings focused on definition and goal understanding, procedural education, QI projects. We get sites to present what they're working on. We rely a lot on Survey Monkey, hey, what are you doing? What do you feel like you need help with this month? What do you want to see presented? Do you want us to ask a physician to present? I'm going to tell you we have a YouTube channel. This is all very new to us. We have a new manager. And she hired a communications person. And I thought, what in the world do we need a communications person for? But she created a YouTube channel. And she created a newsletter and a blog and upgraded our website. So I'm like, wow, look at all this stuff. So I asked one of our echo physicians to make a presentation for tier echo values. And we put that on our YouTube channel. And it's been viewed over 12,000 times for our little collaborative. So it's like really surprising to me that we went from, you know, where we started to now we have people all over looking at our presentations. And I'm happy to say, I just asked them, would you please present to our group? Would you present to our coordinator and abstractor group? He didn't present to a physician group. He didn't present at a physician meeting. I asked him to present to our coordinators. And he said, yes. I will create you a presentation. And now it's available to the world. You can Google it, Dr. Harris. And I'll show you where you can find it on our website later. The other thing we have is we have Structural Heart Coordinator meetings where we bring our mid-level providers together for educational speakers, mentoring and best practice creation. We spent about a year and a half creating a TAVR readmission prevention best practice. And that was then sent out to the whole collaborative to give feedback on. And when we got the feedback then we said, okay. It's good to go. We put it on our website. We're currently working on a shared decision-making, Smart Phrases, Checklist and Education. All of the things on MISHC.org, everything that we've talked about is public-facing and free. So you can go to MISHC.org and see those things. We also have a Publication Committee and Physician Best Practice Committees. I'm going to show you, I guess I'm going to show you that in a minute. So you'll see those. Our Physician Best Practices are currently working on HALT and 1-Year Valid Durability. So the other thing we do, we get a data feed from TBT. And this is one thing that Blue Cross pays for. They pay for the data feed. And because of that, then we have TAVR, MTR and TMVR reports. At the discharge level, 30-day 1-year follow-up, we do M&M reports, quarterly enrolling for quarters. We highlight MISHC goals. We have CMS requirements and outcomes. And then at the end of the report, we have site-blinded graphs where the sites can see how they're doing compared to the state on multiple things. We also do end-of-year reports. We do 3-year reports for expanded data tracking. And we do end-of-year risk-adjusted reports for six variables, mortality, stroke, transfusion, contrast-induced nephropathy, bleeding and VASC comps and readmissions. If you know anything about Michigan and PCI and anything about Michigan at all, we are big into contrast-induced nephropathy. And we have Dr. Gurm which is like, that's his thing. And he's been presenting on that forever. So we have that contrast-induced nephropathy, which is a smaller bump compared to AKI that we track on all of our patients. And we found that that tracks to mortality. And we track that very closely in all of our procedure types. The other thing we provide to our sites is a report-finding spreadsheet. And this is an example of that. It's just a once-a-year look at how they're doing compared to what we have set as mission goals, how they're doing on the KCCQ, so the CMS requirements. And then we have that survival with sustained quality of life. They love looking at that. They love to see if they're doing better than the nation or if they're doing better than the collaborative. They love looking at that one. And I'm going to tell you, if you're starting with quality and starting to present, and I'm saying this, I know there's all levels here. And I'm sure there's people doing way more than we're doing. But I'm just saying, if you want to start somewhere to get some attention from your physicians, looking at that one is a good one. They love to look at that. So we always show that. And this is a made-up site. So we have site numbers, Site 5. We don't have a Site 5. It's made up. But that collaborative number is true on the left. So then I show them other things they're interested in. Of course they're always interested in embolic protection. When are we going to have an embolic protection that shows some data that shows it's effective so the sites will pay for it? I'm going to tell you Michigan has 30 sites. We have seven sites using embolic protection. That's the 40%. Seven sites. All the other sites are like, no. They won't pay for that. There's not enough data to show that it works. And so that's always a big discussion. Shared decision-making and cardiac rehab prior to discharge, of course those are our big things with the new version. And we're working hard on making sure everyone's doing that. I'm going to tell you, it says 100% on some of these shared decision-making. But then I do the chart review and I'm like, I don't see it. I don't see this at all. So that's why we decided that we needed the best practice. We needed to give them some smart phrases. We needed to show them what it means to say shared decision-making. Because they'll argue with you all day that they're doing it. I say, I see you're doing it. I believe you're doing it. I don't see that it's documented that you're doing it. So that's a big one right now. And then the other outcomes, I don't ever green or yellow any of the outcomes. I just put them on there. And we have a long — this is just a sample of it. As Joan said, I go to every site every year and I look at their cases. We call it a site visit. We don't call it an audit. For one, there's no penalty. For another, I don't give them a score. But I give them a long spreadsheet of everything I find in the chart review. I look at all of the procedure types and I look at 30-day and 1-year follow-up as well. I see if they're doing their follow-up at site. I used to kind of push that they need to get those patients back at their site at seeing their team. But things have really loosened up lately. Then after I do the chart review, we schedule an interview with their entire Structural Heart team, quality admins. I've had CEOs, COOs, CFOs. I've had quality people in the room. Joan actually phoned into one of them one time. Depending on what we find and how, and I'm going to tell you I have 30 sites, 10 sites are gung-ho, doing everything they should. Probably another third of the sites are doing the best they can. And then probably the rest of the 10 sites, there's probably three that are like, what? Do I have to put these cases in the registry? And then there's a seven that are like, eh, I'm doing the best I can. But I know what you're talking about. So the exit interviews sometimes will also be eye-awakening to some people. And I invite, I send out the invites myself. I invite their entire team that we have in our contact list. So we call them physician champions and every participating physician. We have echo physicians for tier procedures in our contact list. So I invite everybody. We discuss the chart review findings. We discuss those report findings that I showed you the spreadsheet of. And the goal progress, I want to know what QI projects they're working on, any opportunities for improvement that I see, including documentation, which is big. If I see that they're not documenting, I say, okay, this is what you need to work on. And I say, if you were to be audited by CMS, this is what you would find, and I tell them. And then at the end of all that I send them a summarizing letter and I send it to every person in their contact list. And then during those site visits, sometimes I find challenging cases and we invite them to present at a meeting. And also because I told you we have this new newsletter with our new communications person, I find sites that are doing so well or have made such progress that we highlight them in our newsletter. And we say, hey, are you willing to present your progress and share it with the whole state? And they're so excited. So this newsletter thing is the greatest. They're so excited to present. And if they send a picture of their team, I love that. But not many people will, which I wish we would. And if you look at Michigan.org, that front-facing photo, I demanded that we have a Michigan team. That's the Henry Ford team on our front-facing photo, which is cool. Because our communications person wanted to just pull stock photos. And I was like, no. We need teams. We have teams. Let's pull our own teams. Okay. So let's say, what have we been successful with and what—I'm going to tell you some things we've had some challenges with. The biggest thing we've created, and it wasn't easy and it took a long time, is we have strong relationships that have been built between the collaborative members and our coordinating center. I've been in the same job since 20—so I did PCI before this. So that helped. Then I already knew those physicians. And I worked in the cath lab before that. And I helped our cath lab get ready for TAVR. So it helps that I built all those relationships. But also being persistent and being available and being willing to answer questions and being available. You can text me. You can call me. You can email me. You can reach me at any point if I'm not in a meeting or I'll get back to you soon. So I think that helps. We do conduct new coordinator definition and expectations training. We meet with new sites as they're planning to open their Structural Heart Program. So I have a site that's going to start in the spring of 2024. I've met with them like twice already, say hey, you need to get your ducks in a row. And these are the things that I find that are really challenging for every site to get done. The KCCQ of course, number one. And getting that follow-up, those patients ready for follow-up and the expectation that they have to come back to the site for a full year, we need to get that education in place and have them understand that before they even open their program. I meet with coordinators that want to review their QI presentations. So it's the expectation if we're giving data and we have data, the whole reason we're doing it is for quality and to improve these patients' experiences and care. So we ask that the sites at least have one QI project going at all times. If you need help, I'm going to help you. If you need to figure out where to start, I'm going to help you. So that's been a big success. This is the first year that every site has submitted a quality project on paper with a project form. So we're really excited about that. And then every site is going to present at meetings their work. I also partner sites together that are either working on the same metric or if one site has created this amazing QI project and another site is just starting, I'll say, hey, let me hook you up with this person and they can help you. Our sites share, as I said, challenging cases. They share documentation templates. They share order sets. And they come together to create best practices. And when they create those best practices, a lot of times they're sharing documentation templates. They're sharing order sets, things like that. So that's where we've been successful. This is our mishick.org and our list so far of best practices that we've created in the last couple of years. Obviously you'll see nephrology there. We have a TAVR readmission prevention best practice that I told you about. Conduction system abnormalities, antithrombotic therapy post-TAVR. And we got one site this year that turned in a single antiplatelet QI project that they're working on that they want to work towards. So that's that. So over time we have chosen goals that focus on CMS and TBT requirements. You can use a lot of leverage with that CMS NCD to get started, to get your team started to thinking about goals and tracking goals over time. And then we track them in the report. We highlight them as goals. You could highlight them in a spreadsheet and say these are the goals we're tracking. And then we set a goal. And then we got a national speaker to present. And then we set a goal for matched pairs, like KCCQ just as one, like one baseline or one 30-day. But we need them to be matched pairs. We need KCCQ at baseline and 30 days combined. We need to show that progress of that patient. And I use Joan's phrase all the time that CMS wants to see improved quality of life. And that's the most important thing. I use it all the time. And I say that's why you need to do the baseline and the 30-day and the one-year. And as a collaborative we show improvement over the year. And these are just things that we show to our collaborative at our annual meetings, our collaborative meetings. We always do a little update on where we're at with some of our goals. We've worked really hard on KCCQ collection. We had six new sites. And I'm not saying that's why we had a little bit of a decrease. But any time you add new sites in a year, then you have a decrease. But we've worked really hard to increase that. And we've had an acceptable quality of life which is the 45 at 30 days and not decreasing more than 10 from baseline. So we've had that. And any time that we can show our progress along with national progress, we do that too. And you can do that with your site. You can show your site and national progress in spreadsheets. So we have a lot of challenges. On top of meeting metrics, specific goals, we also have challenges of identifying topics that keep both the interventionalist and the surgeon in the room and want to get them in the room. And I'm going to tell you, we have worked probably five years and are finally next month in November at our collaborative meeting, we're going to have an unblinding, which means everybody's data is out there with nobody's sites hidden. And we've never done that before. And people have fought and fought against it. But we finally got it agreed to. Not only that, it's going to be MISHC, which is TVT data and STS data, and we're doing some TAVR-SAVR unblinding data. And this is going to be a big deal for us. And it took a really long time. But the physicians love that. They want to see it. I'm sure there's some sites that don't love it. But everyone has agreed, which is amazing. And so we have Dr. Deeb, he's on the TVT Steering Committee. And he is a cardiothoracic surgeon. And he has always made presentations on lifetime management for these valves. And that has been our primary focus and heart team. We've always had a portion of our meetings being heart team focused and lifetime management. So that has turned into our primary focus. And so of course, some of the challenges are location of meetings. You saw our state, you know, some of the people in the UP are very frustrated that the majority of our sites are in southeast Michigan and a lot of our meetings end up there. I told you about unblinding data. And then we added mitral procedures, which has been a whole new challenge. And we have some ambitious future plans. We already are inviting ECHO physicians to our meetings. But this year we got every ECHO contact in every hospital and we're inviting them to the mitral tier meetings. We're going to look at physician-level reporting in the future and some AUC peer review. When I say peer review, we do blinded cases and we send them out to other hospitals and we have them review the case and give feedback. We do it in PCI and we do it in vascular surgery. So this is going to be a giant thing, but that's something we're looking forward to in the future. All right. So what can you take home? So systems can mentor new sites and work with them to ensure requirements are in place just like I do. If you have a system hospital that's going to be starting a TAVR procedure, you should reach out to those physicians and say, hey, how can I help and who are you hiring to do this abstraction? Sometimes I'm going to tell you, one of our Michigan coordinators is doing all three sites in a system. So it might be you. So if it is you, then you definitely want to reach out to that site and figure out who the physicians are and who the Structural Heart Coordinator is so that you can get some of these documentation things in place before they start. You can do virtual meetings. They can be scheduled to discuss quality processes, challenges, publications. You can get one of your local physicians to do a presentation on echo variables or something like that. I guarantee you if you ask your physician, can you find someone to talk to us about whatever you're having a hard time about, I'm sure that they can recommend someone and you can have a virtual meeting if you could get a few people together. Those report-finding spreadsheets you can use with your team, I'm going to tell you, if you really want to start something with your state, I looked in the Participation Directory on the TVT website. If you look per state, there's probably about half of the emails in there, even of my own state. You can get into that site profile and add your email and I'm encouraging you to reach out to other people in your state that you see. You can look under the Participation Directory. You can download it as an Excel spreadsheet and then filter it by your state. And then you can reach out to at least a few people because I guarantee you there's probably at least a third if not half of your people are listed in there with their email address. And then you can also reach out to the PCI or STS person at your site and say, ask them to ask the other people if you know anybody that's doing TAVR or if they're doing anybody. Reach out and see if you can find other people to collaborate with. So something I found valuable, I have probably about six Structural Heart Coordinators that also do data abstraction. They don't have time to listen to the calls. They don't look at the FAQs. I go do their chart reviews and they're like, well, when did that definition change? I didn't see that. So it's very helpful if there is an email sent out that can summarize those things or if you just save all the FAQs into a PDF that you can do and forward it to people. You have the best practice protocols are available on MISHIC.org. There are documentation templates. And those of you who have EPIC, have you found the EPIC Community Library? There's a link here. If you log into that EPIC Community Library and you can see the community library I have circled up top, if you put in that content, all content space, TAVR, TIER, whatever you want to put in there, you want to put aortic valve, mitral valve, whatever you want to put, it will pull up tons of documentation templates. So my goal is to develop a MISHIC.org or a MISHIC documentation template folder within the EPIC Community Library. We're already working on that at vascular surgery, but I don't have it yet for MISHIC. But we're going to work towards it. But even if you don't, go in there and you have to create your login. But it's through your hospital. If you have EPIC, you'll just log in through your hospital and you can find all kinds of documentation templates. There's thousands. So if you're looking for something and you have EPIC, go in there and see if you can find it. And then you can pull it from there. The other thing I'm going to say is, so I had a meeting and I asked our MISHIC coordinators, would you be willing to help mentor or show somebody that can't figure out how to pull data from TVT? Or would you be willing to help someone on a QI project? I got plenty of volunteers because that's what we do. We help each other. And so if you want someone to mentor for data abstraction, Structural Heart Coordinator participates, if you want someone to like help you with a local meeting or a state meeting or review QI opportunities, projects or presentations, I'm going to say call me. Call me. Well, I have a QR code here. My slides are available on the app. Call me. Text me. Email me. I will either pair you with someone or help you myself. We're willing to help. That's what we're going to do. And there you go. There's our MISHIC.org. We're on all of the socials. And we have a website. And I'm going to tell you, I'm not on the socials. I don't do that. But you can call me or text me. Anyway, that's it. Thank you very much. »» All right. I'm Holly. I'm going to kind of talk about the same things as Cheryl, but instead of a statewide 30 sites, we're going to talk about a healthcare system, and talk about how we did our collaborative and then show some of the outcomes that we have. And to kind of get started, I am from Baylor, Scott & White. And this just kind of highlights, you know, what our healthcare system is. So Baylor, Scott & White is, as shown here, is within Texas. We're the largest nonprofit system in Texas. We have kind of a grouping of facilities that go across the Dallas-Fort Worth Metroplex, which is where I'm based out of. But then we also have Waco Temple and Round Rock Austin area. And within those areas, we're looking at 51 hospitals. We have also 254 outpatient clinics. We have 30 ambulatory surgery centers. But what that includes for our cardiovascular services is 17 cath labs. We have eight cardiac surgery programs. And then we have, right now we just added, we have seven programs doing TAVR or structural heart. And during our collaborative when we first started, we had six. So that's just kind of the outline for the programs within our healthcare system. And what we see too is when we look at our annual volumes across, we have a very wide range of different facilities. We have three sites that have been doing this since commercialization. And then we have some that were a little later. And what you can see there is even so, we have sites that do a lot of cases every year. And then we have some sites that, you know, are not as much volume. But what that does is allows us to share across a greater continuum of different patient populations and then also, you know, different care teams. Because each facility is going to have their culture that's a little different. And so we're able to have robust conversations. So as we look at that, our collaborative started in the late 2019 as public reporting was getting talked about. There was more reports within TVT. And so as we wanted to prepare for that, we wanted to look internally so we can share best practices and start our quality projects. And what we ended up doing is Ellie's team, I started this project as a coordinator myself, not as a program manager. And we ended up with our kind of secret sauce, as Ellie likes to call it, is going to be getting those key physicians, those with a lot of buy-in, to lead. And what they end up doing is pulling in the other physicians, other groups also, and firing them up. And so for TAVR we do have an interprofessional cardiologist and then also a cardiac surgeon who work together and help to support the teams and then also guide our monthly meetings that we have. So when we started things off and were looking at what we wanted to do, the vision statement listed here was to really be able to elevate our patient outcomes for TAVR across the entire system to come together and align in certain areas and then also talk about best practices and protocols and prepare for that, you know, the public reporting that was coming. So to kind of get that started, this is how we initiated things. So what we did was not quite the same as what Cheryl does in her site visits, but we still also called it a site visit. And that was really understanding what does each program have? What does your staffing look like? What does your imaging, you know, how is that set up? And you know, what do you feel that you all do well? And what are some areas that you feel that you could use some help with? And so we sent those questionnaires out. And then we met with each site individually and presented it as a, you know, a system. And when we looked at some of those things at the system level, we were seeing, you know, how they were selecting their patients, what was their referral process, how did they work up these patients? And in 2019 even, we were talking with sites about what kind of CT scanner they had and finding out that they did not have the best CT system currently. And through the system what we can do is support them and provide that to the facility on why they need to upgrade their CT scanners. We also, you know, Heart Team models, you know, in different areas are not always so seamless. They're not, you know, natural in coming together. In some areas, you know, it was, you know, the birthplace of the Heart Team. So it's understanding how to help them and, you know, set up those kind of keys for success on that Heart Team model. And then also, we were talking about how can we as a system ensure, you know, identification of patients besides the referral process and how can we streamline that internally? And then also a big thing that I like to always talk about is the education part of it. As we all know, when we start talking to physicians about certain outcomes, they have a very specific definition of what that means to them. So when you come to them with those outcomes, those reports, sometimes they're a little surprised and it's just helping them understand, you know, what their registry is looking for, what's the importance. And I think one of the great things in those companions online is they do provide that clinical background so that when they come and they go, well that's not how I want to define my vascular complication, you know, you can direct them to the VARC criteria that is used and it's outlined. And that's one thing that we have gone over several times, is to really understand those minor and major and how it's classified. And so there's a lot of that portion of it too. And even within our system when we talk about getting our data in, we have very different abstraction models across all of our systems. We have facilities that are real-time, in-house abstraction. And then we have some that are kind of hybrid. So they may be getting some of that data in, but then also partnering with that third party to kind of do the filler part. But they're also reporting out to their physicians in a little bit of a real-time thing to let them know things that might be popping up. We also have some that are purely third-party abstraction. So what we do is we do the whole education part on that and working with how their model is in their data. Because you do get a lot of questions sometimes on, well, how do we know that data is correct? And so it's understanding those definitions. And educating everybody from the valve coordinators to those people who are doing the data to those that are doing a little bit more of just the reporting out and the quality improvement. So as we looked at those themes and were talking with the team as to what was important to them, they came up with a roadmap. And that roadmap is here. And what we kind of focused on in what Joan was talking about, the money slide, is focusing on some things that were going to contribute to a mortality risk reduction. That's one thing looking at the system data that we did. That was something we wanted to work on. And what we did was view some of those things that were happening that were going to impact patients and identifying them so that what we call the Cohort C, what patients, you know, is TAVR the best option for them? Is it going to give them the quality of life that they would like to have? Also we do have sites that were very established and had some, you know, more high-risk cases that were coming to them. And how can they help those other sites as they get their high-risk cases to evaluate the best way for them to treat them? Also, you know, we've talked a few times about case reviews. And we do them, try to do them quarterly. Interesting or mortalities, get those to come forward and talk about them. As a system, the one way that we do get a lot of our physician buy-in and getting them to the table is we don't blind our data. It is very transparent. And for our physicians it's very motivating to get them to look at it. They ask more questions. They get really involved in understanding how things kind of come together for those patients. And also then we have had, as I'm sure you have also had, physicians who think they know kind of an estimation of what their practice is like. And you know, I don't have that many pacemakers put in. But when you show them the data, that 30-day data of what's happening even, then you know, it highlights for them maybe some areas where we can focus and help them come together to talk about different things. And after that, what they kind of wanted to do after we were looking at those major mortality reduction is then going step-by-step with the process. So pre-procedural, renal hydration and protection protocol. And we talked about dental clearance and PFTs. You know, we had a great discussion on, you know, what was everybody's current default? Was it working as well? And then right now one of the big things that we are talking about alongside, of course, the Michigan Collaborative for AKI is low contrast. So we do have a facility that uses very low contrast. And how can that be expanded across the system to still get your scans and get images for evaluating patients? And so they're looking and we're looking at things like the low contrast, which is a 40cc protocol for all patients for those images. And then also interprocedural, we do have a kind of flow chart for monitoring patients afterwards. So those with a new left bundle branch, you know, how are we going to as a system look at that, identify those patients and monitor them in a way to ensure that they don't have any events after TAVR at home? We also do a lot of alternative access. So the preferred method for many of our physicians is transcarotid. So how do we partner those sites that are very comfortable with transcarotid with those that are not so comfortable? And is it something they want to learn? Is it something that we can equip them with? So they can offer that to their patients as well locally. And then also we talked about embolic protection and guidance and how to do that and reduce the stroke. But with the current data, most of our sites for the most part do not use embolic protection unless it's in some sort of research study or some sort of protocol at this point in time. So they do have just a couple patients where if they have a lot of calcium, you know, that sort of thing, then they'll go ahead and kind of set that up. And then also we talk about closure devices and, you know, this kind of in the hospital type things, and then to go and move on about the post-discharge. So the biggest thing for us is our patients can come from all over. And all over can mean it coming from different states. Or as you get closer to that central part of Texas, it gets a little more rural. So how do we coordinate with those patients during that 30-day and especially that one year? And those things we're still talking and we're still, you know, moving through those compliance methods. And much like Cheryl mentioned, we talk about HALT. We talk about those guidelines of understanding what the follow-up echoes mean, when to start talking about some of the valve deterioration, and what should those kind of protocols look like to catch that early for early treatment. So it's an ongoing process. And my next slide is the money slide. And we have had great success. But also in this slide I want to show you all that, you know, it's not all going to look pretty all the time for everybody. And those are, you know, you continue to highlight some opportunities because the quality improvement process is just an ongoing circle. And it repeats. And you just keep moving forward together as a group. So this is our lovely money shot. So when we initially started wanting to look at the system outcomes, you can see that our system mortality was higher than TBT, both 90%, 50% and observed at 3.2. So going into that, you know, end of 2019, talking about, hearing about public reporting, we were starting to talk with sites saying we're going to start this quality initiative. So that can get everybody a little nervous. And so people are getting ramped up, getting ready. And so at the end of 2019 and early 2020, before the pandemic, we were doing those site visits. We're talking to sites. And so that line is the precipice of our first kickoff meeting. And you can see that following that, you can see those stark movements of one, not just mortality going down, but also it's everybody's mortality. Coming together, talking, collaborating really does provide a method for physicians and the teams to get together and impact patient care and going in the same way. So again, you can see we're all still trending down. You can see how the pandemic affected. And since we are in two very different kind of sections of Texas, Dallas got hit a little differently in a different timeframe than our central Texas got hit. And you can see that on this slide. While I do have it blinded on here, I can say like the gray and some of the green is actually our central Texas folks. And you can see they got hit much later, almost a year and a half after the major pandemic kind of hit Dallas. So you can see how that really affected everybody. But what you can see now as well is after the pandemic and looking towards 2022, that we're coming back together again. And we meet monthly. We're open to all. I get questions all the time from different physicians and it is a power of a system. Our facilities may need assistance with getting that CT scanner or we're talking about now system contracts for imaging. And it also has helped us in some other things such as doing strategic sourcing, getting better contracting for our facilities in our system as a whole. We really, they come together. They come together often. I don't have to beg anybody. And that's just a testament to how we started. And at the same time also just how much physicians, they do want to come together and talk. They love talking about the new technology. This is specifically TAVR, but we are talking a lot about the mitral tear. We started our collaborative as a mitral disease process, which will be an interesting seed how it goes. We have surgery, we have transcatheter, we have heart failure. And so how are we working together as a system and at that whole patient for that disease process? So that is what I have for you all today. You know, taking the great things that the MHSIC has done and not working at the same time but in a state level or in a system level, you know, we can show some great data on how to help you and your facility. We're always open as well to share our protocols, you know, to answer questions. And my information is also up on the app. So feel free to contact myself with any questions. And then I will circle it back to Joan for you all to ask questions in the app. »» Thank you, Cheryl. And thank you, Holly. We have a couple of minutes. And that last slide is so powerful. I mean, just post that on, you don't have to say it's Baylor Scott-White, maybe. But first of all, the takeaway is it's unblinded, oh my God, that's scary. And you're starting to do that, that's scary. But take that slide and just post it on the scrub sink and say, we can do this, right. That's teamwork. That's collaboration. And I think again, following these three days, that's what we tried to do to make sure that you're leaving with the skill set. I'm going to scoot over here and see if we have any questions. Did anybody put questions in? Or just yell them out? We'll just have a couple of minutes. »» So I'm seeing a lot of great work, great work. Shared decision-making at either system that works best. Paper tool versus EMR templates. What best works for shared decision-making? »» I'll go first. I think that's one of the things that MISHC is really focusing on. So with our different sites, we do have very different profiles on how our patients are evaluated. So we do have a site that's a one-stop shop. These patients come in one day, they get everything done. So it is a long day, but they start first thing in the morning with any imaging. They do their lab work. And then they go through in the afternoon and actually get seen. And by getting seen, they quite literally will have four or five physicians in the room with them. Both the ECHO, our imaging specialists are very participatory in the clinics there along with a surgeon and cardiologist. Now kind of like what Cheryl says, I know for a fact in that area of course there's shared decision-making. We actually call it a war room for our clinic, that clinic for that purpose, is because there are some difficult conversations that happen. But then they go to the patient and they actually go through all the different options. But actually getting that documented sometimes can be that difficult piece. And then we have other facilities that do very segmented. You might have a clinic that is a valve clinic, but they see a cardiologist separate or they see the surgeon separate. They may get their imaging kind of all over. And then periodically they'll pull all of that together for a patient selection review and then talk about the patient and get that going. So for those it's even more important to try to understand how to have a collective documentation thing. But that's what we kind of do on our end. And I would say we're very much looking forward. That's one question I do get often, is there a form? Is there a specific way that we can actually get this together? »» Any thoughts on shared decision-making or work in progress? »» I'll be very quick. We did a lot. If you Google, there's a lot on shared decision-making. So we pulled that together. We pulled an education piece. We pulled some Smart Phrases and we created a tool. It will be available on the mnishuk.org website soon. That was the easiest thing we've ever done because there's so much out there about that. So you can easily find a Smart Phrase online. »» How did you lower that mortality rate? Is there one silver bullet? »» I want to say talking about the difficult conversations of patients that TAVR is not going to be beneficial for them. It's understanding that cohort C, I have to say. Because you do, you want to offer these people the latest technology. You want to give them every opportunity. But unfortunately sometimes even as Dr. Arnold was talking about, TAVR is not going to do that for them. And it's those difficult conversations with those patients, the patient's families. And I think once we kind of set those guidelines, it helps them have those conversations and then the better patient selection. »» So we're a little bit over. There's a lot on here. And I thank you. But before you leave, when the three of us were talking to Dr. Arnold, I don't think she realized, and I don't think it's just me. It was like meeting a celebrity. And so we tried to impress upon her, you're really cool. And if you saw her, she's just not into it. So of course, in my simple mind, I was like, you're like Taylor Swift. So I said we're going to make Swifty bracelets and she was like, really? I think she might have canceled, but it was too late. So for those of you who have stuck with us for three days, come up and get a KCCQ or a TABA bracelet. Thank you very much. »» Perfect. »» We all contributed to the... »» Thank you.

TVT Registry

Program Managers

collaboration

knowledge sharing

MISHIC

patient outcomes

Baylor Scott & White

collaborative efforts

patient-centered care

continuous quality improvement