Quality of care and reporting

Measuring quality of care

Key Performance Indicators

Based on clinically relevant procedural outcomes, VCOR has adopted a number of key performance indicators (KPIs) to monitor and benchmark the performance of health services in their delivery of quality cardiac care. The KPIs are determined by the Clinical Quality Committee and relevant Working Groups.

The KPIs reported for the VCOR PCI module are:

  • In-hospital mortality
  • In-hospital major bleeding
  • Length of stay
  • In-hospital unplanned revascularisation
  • Door to balloon/device time for STEMI patients
  • 30-day mortality
  • 30-day unplanned revascularisation
  • 30-day major adverse cardiac and cerebrovascular event (MACCE)

The KPIs reported for the VCOR CIED module are:

  • In-hospital mortality
  • 30-day mortality
  • Successful device implantation without in-hospital complications
  • 30-day unplanned cardiac readmissions
  • 30-day device related re operations
  • 30-day device related infection rate

Risk-adjustment

VCOR have developed risk-adjustment models for the PCI KPI’s In-hospital major bleeding and 30-day mortality. The risk adjustment process allows data to be presented in a way that controls for variations in patient population and is a fair and more representative way of benchmarking hospitals’ relative performance.

Clinical quality review process

The VCOR Clinical Quality Committee (CQC) review KPI data quarterly and annually. Data is reviewed for the current review period and compared against the previous quarter/year. Data are displayed in the form of funnels plots to assist the benchmarking of performance of the contributing VCOR sites. Variation is managed in accordance with the VCOR Clinical Quality Reporting and Communication of Variance Policy.

VCOR reporting

VCOR produces routine, individualised site reports on a quarterly basis. These reports are based on data collected in the previous quarter and identify how sites are performing based on each of the relevant Key Performance Indicators (KPIs). They compare individual site performance against the group cohort but also provide sites with the opportunity to review their own performance across reporting periods.

Reports are reviewed by the CQC and/or Steering Committee before publication or dissemination.

The reporting function of a clinical quality registry is its most critical function. VCOR reporting categories are as follows:

  • Site Reports: are provided quarterly for PCI and annually for CIED. These reports focus on data completeness, data quality, clinical quality benchmarking and other clinically relevant data.
  • Public Reports: are delivered annually. They review project progress and reflect on de-identified results for clinical data from the previous year.
  • Audit Reports: PCI sites are provided with feedback relating to the outcome of regularly scheduled site audits exploring data quality and data completeness in VCOR. These reports are individualised and provide feedback about case numbers and data managers practice.
  • Online Reports: are available to PCI sites and allow for download of their VCOR data at any time from the online system. Authorised users are able to run reports on their site and clinician data. They can also produce reports for the entire cohort to compare their data to 'all sites'.
  • Clinician report: allows PCI Clinicians to access information on the cases where they are assigned as the Primary Operator, across all VCOR sites that they are registered at.

For further information on VCOR reports please refer to the VCOR Reporting Policy or contact us at vcor@monash.edu