Exceeding the Standard in Vascular Verification Program Data Collection and Surveillance

General Information

Institution Name: Baylor Scott & White Heart and Vascular Hospital-Dallas

Author Name and Title: Brandi Crow, MSN, RN, NEA-BC, Regional Director of Quality, Lindsey Teefey, MSN, RN, NEA-BC, Director of Clinical Quality, John Eidt, MD​, Chief of Vascular Surgery 

Name of Case Study: Exceeding the Standard in Vascular Verification Program Data Collection and Surveillance:​ Aggregating Event Reports, Patient Reported Outcomes, and Registry Data to Drive Quality Improvement 

Identification of Local Problem

Traditional quality monitoring methods often fall short by relying on fragmented data sources, limiting the ability to evaluate surgical outcomes fully. In preparation for participation in the ACS Vascular Verification Program, critical gaps were identified in combining clinical outcomes, process measures, and patient experiences, resulting in missed opportunities for improvement in patient care and safety. 

Context of the QI Activity

This quality improvement (QI) initiative was conducted at Baylor Scott & White Heart Hospital – Dallas as part of the ACS Vascular Verification Program. The goal was to integrate diverse data sources—including registry data, adverse event reports, and patient-reported outcomes—into a unified system to provide a holistic, real-time view of program performance.

What were the interventions?

• Aggregated data from:
  • National vascular registry
  • Adverse and near-miss event reports
  • Internal electronic data warehouse
  • Patient-reported outcomes (via experience surveys and post-discharge phone calls)
• Applied a structured case identification and review process (initial review → focused review → second-level committee review).
• Benchmarked outcomes against ACS Vascular Verification standards, with emphasis on data-driven quality improvement across all levels of care.

Cost and Funding Sources

This initiative was institutionally supported with existing staff and resources by Baylor Scott & White Heart and Vascular Hospital as part of its commitment to ACS program participation and verification standards. 

Overall Results and Analysis

• Integration of diverse datasets created a comprehensive view of program performance and patient experience.
• All ACS Vascular Verification Program standards were met, with two standards recognized as exemplary (Hospital Commitment to Quality & Patient Safety, Peripheral Artery Disease protocol).
• Data-driven improvements resulted in:
  • Improved patient experience and engagement
  • Enhanced treatment efficacy and safety
  • Strengthened institutional commitment and interdisciplinary collaboration

Limitations

• Resource-intensive data collection and integration across multiple sources
• Potential variability in patient-reported outcomes (survey and follow-up participation)
• Reliance on institutional infrastructure to sustain long-term improvements 

Lessons Learned

• Aggregating Diverse Data Sources Enables a Comprehensive Understanding: 
  Integrating clinical, adverse event, and patient-reported data provides a complete picture of program performance, uncovering issues that single data streams might miss.
• Strong Institutional Commitment and Multidisciplinary Collaboration are Critical: 
  Leadership support and active involvement across all levels—from physicians to nursing to administration—drive a culture of continuous quality improvement.
• Patient Engagement Enhances Quality Improvement Efforts: 
  Actively capturing and incorporating patient experiences through surveys and follow-up calls results in a higher case capture volume, better patient-centered care, and improved outcomes