Cardiac Surgery Quality Assurance Program Template

1. Program Overview

1.1 Purpose

• Ensure excellence in cardiac surgical care
• Maintain compliance with regulatory requirements
• Establish systematic quality monitoring processes
• Drive continuous improvement in patient outcomes

1.2 Scope

• All cardiac surgical procedures
• Pre-operative assessment and planning
• Post-operative care and follow-up
• Staff competency and credentials

2. Quality Metrics and Monitoring

2.1 Clinical Outcomes

• 30-day mortality rates
• Surgical site infection rates
• Readmission rates
• Length of stay metrics
• Post-operative complications

2.2 Process Measures

• Time to surgery for urgent cases
• Operating room turnover time
• Prophylactic antibiotic timing
• Beta-blocker continuation
• Temperature management compliance

3. Data Collection and Review

3.1 Data Sources

• Electronic health records
• STS database participation
• Patient satisfaction surveys
• Incident reports
• Peer review findings

3.2 Review Schedule

• Monthly mortality and morbidity conferences
• Quarterly quality committee meetings
• Annual program evaluation

4. Performance Improvement

4.1 Methodology

• PDSA cycles
• Root cause analysis
• Failure mode and effects analysis
• Best practice implementation

4.2 Action Plans

• Identify improvement opportunities
• Develop targeted interventions
• Monitor effectiveness
• Adjust based on outcomes

5. Staff Requirements

5.1 Credentials and Privileges

• Board certification verification
• Procedure volume requirements
• Ongoing education requirements
• Performance review process

5.2 Quality Team Structure

• Quality director responsibilities
• Data coordinator role
• Committee membership
• Reporting relationships

6. Documentation Requirements

6.1 Quality Records

• Meeting minutes
• Action plans
• Outcome reports
• Performance improvement projects

6.2 Review and Storage

• Document control process
• Retention requirements
• Confidentiality measures
• Access protocols