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What Quality Metrics Should Hold a Perfusion Provider Accountable? A Contracting Framework

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The most useful quality metrics for a perfusion agreement already exist, written in mandatory language, in the AmSECT Standards and Guidelines for Perfusion Practice. A hospital that converts the relevant standards into contract obligations gets an auditable quality program without designing one from scratch: board certification of every perfusionist, annual competency assessment, annual continuing education, documented onboarding, a written protocol for each standard, a checklist retained in the permanent medical record, a complete perfusion record, a defined handoff protocol, participation in the post-procedure debrief, active participation in institutional quality programs, and data collection through a clinical registry or database. Then add a small number of institution-specific operational and outcome measures on top.

What should not be in the agreement is a mortality target. The reason is worth understanding, and it is covered below.

Why perfusion quality conversations usually go nowhere

Two failure modes recur.

The first is adjectival. The provider describes its clinicians as experienced and its program as data driven, the hospital has no way to test either statement, and the discussion resolves on price because price is the only comparable number in the room.

The second is over-reaching. A hospital determined not to repeat the first mistake writes outcome targets into the agreement, often cardiac surgical mortality or acute kidney injury rates, and discovers at the first review that neither party can attribute movement in those numbers to perfusion practice. The metric then gets quietly ignored, which is worse than not having written it, because the agreement now contains a term nobody enforces.

The way through is to separate what a perfusion provider controls from what it contributes to. Practice standards, credentialing, documentation, and process adherence are controlled. Patient outcomes are contributed to, alongside surgical technique, anesthesia, patient acuity, and postoperative care. Contract on the first category. Monitor and discuss the second.

Start with the standards that are already written as obligations

AmSECT’s 2023 Standards and Guidelines for Perfusion Practice distinguishes Standards, defined as practices, technology, or conduct of care that institutions “shall” meet, from Guidelines, which state what should be done. That distinction is the useful part: the Standards are already phrased as requirements, and a substantial number of them are directly verifiable.

Qualification and competency, Standard 2. Standard 2.1 requires that a perfusionist who is board certified by the American Board of Cardiovascular Perfusion, or who demonstrates equivalent qualifications and competency, shall conduct cardiopulmonary bypass procedures. Standard 2.2 requires that perfusionist competency shall be assessed annually to evaluate compliance with departmental protocols. Standard 2.3 requires annual participation in perfusion-related continuing education. Standard 2.4 requires that support staff be available on site to assist the primary perfusionist during bypass. Standard 2.5 requires a documented onboarding outline so new hires are oriented and able to safely perform perfusion responsibilities.

Every one of those is auditable on demand. Ask for the roster with certification status, the annual competency assessments, the continuing education records, and the onboarding documentation. A provider that cannot produce them within a few business days is telling you something.

Credential verification is unusually easy in this specialty. The ABCP requires certified clinical perfusionists to recertify annually, documenting a minimum of 40 clinical activities per year with at least 25 as primary clinical perfusion activities, and to earn 45 continuing education units across each three-year period with at least 15 in Category I. ABCP also maintains a public verification tool for active status. A hospital can check the credential independently rather than accept a list.

Protocols and documentation, Standards 1, 4, and 5. Standard 1.1 requires that an institution or service provider shall develop and implement an operating procedure for each of the standards, which means a provider should be able to hand you a protocol set mapped to the standards. Standard 5.1 requires use of a checklist for each cardiopulmonary bypass procedure, and Standard 5.2 requires that checklists be included as part of the patient’s permanent medical record. Standard 4 governs the perfusion record and what it must include.

The checklist requirement deserves emphasis because it is the easiest audit in the entire framework. Pull twenty recent cases and confirm the checklist is in the record. It either is or it is not.

Communication, Standard 3. Standard 3.1 requires a patient-specific management plan for the bypass procedure. Standard 3.2 requires the primary perfusionist to use a set handoff protocol, with SBAR given as an example, when transitioning care. Standard 3.3 requires participation in the post-procedure debrief. AmSECT has clarified that a debrief need not be lengthy or formal to be effective and may occur during chest closure, which removes the usual objection that there is no time for it.

Equipment, Standard 18. The standards require that equipment be properly maintained and functioning, that preventive maintenance be performed by appropriately trained manufacturer technicians, representatives, or biomedical technicians and be documented, that the organization follow a protocol for equipment failures, that appropriate backup supplies and equipment be readily available, and that the organization follow a protocol for acknowledging and addressing equipment notices such as recalls and advisories.

In a contracted arrangement, decide explicitly which party owns each of these and write it down. Recall handling in particular tends to fall between the hospital’s supply chain and the provider’s clinical operation.

Crisis management, Standard 19. Added in the 2023 update. Ask what the provider’s crisis protocols cover and how the team rehearses them.

The registry requirement is the single best term you can add

Standard 17 covers quality assurance and improvement, and it contains two obligations. Standard 17.1 requires that the perfusionist shall actively participate in both institutional and departmental quality assurance and improvement programs and safety reporting systems. Standard 17.2 requires that the perfusionist shall collect data concerning the conduct of perfusion via a clinical registry or database to advance quality and safety.

That second one is the most consequential sentence in the document for contracting purposes, because it converts “we are data driven” from a claim into a checkable fact. AmSECT does not mandate a specific registry, and its FAQ explains that a clinical registry or database is a collection of information relevant to perfusion metrics that can be reviewed and analyzed to advance quality and outcomes, collected or analyzed at local, state, national, or international level. AmSECT identifies PERForm as its official perfusion registry, and PERForm in turn describes AmSECT as its official national perfusion societal partner.

It is worth understanding what PERForm is and is not, because the honest picture supports a more useful conversation than a simple instruction to demand registry participation. PERForm is embedded in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. It links institutional perfusion data with cardiac surgical data using a published algorithm, and provides participants with quarterly benchmark reports that let an institution compare discrete perfusion practices against other participants and relate those practices to clinical outcomes. It was created specifically because few validated registries capture cardiopulmonary bypass practice in enough detail to reflect it accurately. As published on its own site, it currently reports participation spanning 39 hospitals across 12 states, with 120 surgeons and 208 perfusionists, and has generated 16 publications.

That is a serious quality instrument and also a relatively small one. A national provider will not necessarily be in it, and its absence is not evidence of poor quality.

So the questions to ask are more useful than a yes or no. Does the provider collect perfusion data in a registry or database, satisfying Standard 17.2? Is that an external, multi-institutional registry permitting benchmarking against other organizations, or an internal proprietary database? And either way, will your hospital receive its own site-level data?

Both models are legitimate and both satisfy the standard as written. They are not equivalent for the hospital’s purposes. An internal database can be excellent and is often far larger than any external registry, but the comparator is the vendor’s own book of business and the vendor controls the metric definitions and the analysis. An external registry supplies an independent comparator and validated definitions at the cost of narrower participation. If a provider reports from an internal database, ask who defines the metrics, how the data is validated, and whether you can see the definitions.

Building the scorecard: four tiers

Tier one, credential and compliance verification. Verify at onboarding and annually.

  • Every perfusionist assigned to your facility is ABCP board certified or demonstrably equivalent, verified independently
  • Annual competency assessment completed and documented for each
  • Annual continuing education documented for each
  • Onboarding documentation for every new assignment to your site
  • Written protocols mapped to the AmSECT standards
  • Evidence of registry or database participation

Tier two, process adherence. Audit quarterly on a sample.

  • Checklist present in the permanent record, by case
  • Perfusion record complete against the required elements
  • Handoff protocol used and documented on transitions of the primary perfusionist role
  • Post-procedure debrief participation
  • Equipment preventive maintenance current and documented
  • Equipment notice and recall actions documented

Tier three, operational reliability. Report monthly.

  • Coverage reliability: cases covered as scheduled, and any case delayed, deferred, or transferred for perfusion staffing reasons
  • On-call response performance against the agreed standard
  • Staffing continuity: named perfusionists assigned to your site, and turnover among them
  • Case cancellations or delays attributable to equipment or supplies
  • Safety events and near misses reported, with time to report

Coverage reliability and staffing continuity are the two most predictive operational measures, and they are the ones providers are least accustomed to reporting. A provider whose clinicians rotate constantly through your ORs is a different service than one that assigns a stable team, whatever the credentials look like on paper.

Tier four, clinical measures. Review jointly, do not contract on.

Perfusion-relevant clinical measures are worth tracking and discussing at a quality committee. Blood management and transfusion practice, oxygen delivery management during bypass, glucose and temperature management, and hemodilution are all areas where perfusion practice is a meaningful input and where AmSECT’s standards give a practice reference. Review them as a joint program between the hospital and the provider, with the understanding that they are shared measures rather than vendor deliverables.

Metrics that should not be in a perfusion contract

Surgical mortality. Cardiac surgical mortality reflects patient acuity, surgical technique, anesthesia, perfusion, intensive care, and case mix. No method exists to attribute a change in it to a perfusion provider at the case volumes a single hospital produces. Writing it into an agreement creates a term that is unenforceable and, worse, one that can penalize a provider for accepting higher acuity cases.

Raw complication rates without risk adjustment. Same problem in a smaller frame. If clinical measures are tracked, they need risk adjustment and adequate volume, which is exactly what a registry provides and what a single program usually cannot generate alone.

Cost per case as a quality proxy. It measures something real, but not quality, and treating it as a quality metric creates pressure in the wrong direction.

The honest position is that a hospital contracts for practice standards, staffing reliability, documentation, and process adherence, and it partners on outcomes. A provider that offers to guarantee an outcome should be asked how it proposes to attribute it.

How to run the audit without building a department

The framework above looks heavier than it is in practice. Tier one is an annual document request. Tier two is a quarterly pull of ten to twenty cases, which an existing quality analyst can do in a few hours. Tier three is a monthly report the provider generates. Tier four belongs to a committee that already meets.

Two practical notes. Put the audit right in the contract, since a term nobody can verify is a term nobody follows. And ask for a sample report from a comparable client before signing, rather than a description of what reporting includes. The gap between those two things is where most disappointment lives.

Where SpecialtyCare fits

SpecialtyCare is one of the nation’s largest providers of ECMO and perfusion services, participating in one in seven of all heart surgeries performed in the country each year. Its average perfusionist tenure is more than 8.5 years, which speaks directly to the staffing continuity measure in tier three, and its average client tenure exceeds 10 years with a 97 percent customer retention rate. SpecialtyCare maintains one of the largest allied health databases capturing shareable procedural data in the United States, and it is accredited and certified by The Joint Commission.

Applying this article’s own framework to that description produces a fair question, and hospitals should ask it of SpecialtyCare as of anyone: an internal database of that scale is a genuine asset, and the useful follow-up is who defines the metrics, how the data is validated, whether the hospital receives its own site-level data, and whether the provider also participates in an external registry that allows comparison beyond its own client base.

If you are writing or renewing a perfusion agreement, contact SpecialtyCare and ask for the tier one and tier two items to be reflected as obligations in the contract rather than as descriptions in a proposal.

Frequently asked questions

What clinical quality metrics should a hospital hold a perfusion provider accountable to? The most defensible set comes from converting AmSECT’s mandatory standards into contract terms: ABCP board certification for every perfusionist, annual competency assessment, annual continuing education, documented onboarding, written protocols mapped to each standard, a checklist retained in the permanent medical record for every bypass case, a complete perfusion record, a defined handoff protocol, post-procedure debrief participation, documented equipment maintenance and recall handling, active participation in quality assurance programs, and data collection through a clinical registry or database. Add operational measures for coverage reliability, on-call response, and staffing continuity. Review clinical outcome measures jointly rather than contracting on them.

Does AmSECT require perfusion data to be submitted to a registry? AmSECT Standard 17.2 requires that the perfusionist shall collect data concerning the conduct of perfusion via a clinical registry or database to advance quality and safety. AmSECT does not mandate a particular registry, and its FAQ notes that data may be collected or analyzed at local, state, national, or international level. AmSECT identifies PERForm as its official perfusion registry, and PERForm describes AmSECT as its official national perfusion societal partner. Because both an external registry and an internal database satisfy the standard, hospitals should ask which one their provider uses and whether benchmarking extends beyond the provider’s own client base.

What is the PERForm registry? PERForm is a validated clinical registry embedded in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. It links institutional perfusion data with cardiac surgical data using a published algorithm and supplies participants with quarterly benchmark reports comparing discrete perfusion practices against other participating institutions. As published on its own site, participation currently spans 39 hospitals across 12 states, including 120 surgeons and 208 perfusionists. It is the registry AmSECT identifies as its official perfusion registry, though its participation base means many national providers and hospitals are not part of it.

How can a hospital verify a perfusionist’s credentials independently? The American Board of Cardiovascular Perfusion certifies clinical perfusionists and maintains a public tool for verifying active CCP status. CCPs recertify annually, documenting a minimum of 40 clinical activities per year with at least 25 as Table A primary clinical perfusion activities, and must earn 45 continuing education units across each three-year reporting period with at least 15 in Category I. A hospital can verify status directly rather than rely on a provider-supplied roster.

Should surgical mortality be written into a perfusion contract? No. Cardiac surgical mortality reflects patient acuity, surgical technique, anesthesia, perfusion practice, and postoperative care, and a single hospital’s case volume does not support attributing changes in it to a perfusion provider. Contracting on it produces an unenforceable term and can create a disincentive to accept higher acuity cases. Track outcome measures jointly at a quality committee and contract on practice standards, documentation, process adherence, and staffing reliability.

What does AmSECT require regarding perfusion checklists? Standard 5.1 requires that a perfusionist use a checklist for each cardiopulmonary bypass procedure, and Standard 5.2 requires that checklists be included as part of the patient’s permanent medical record. This makes checklist compliance one of the simplest items for a hospital to audit, since a sample of recent cases either contains the documentation or does not.

How often must perfusionist competency be assessed? AmSECT Standard 2.2 requires that perfusionist competency shall be assessed annually to evaluate compliance with departmental protocols, and Standard 2.3 requires annual participation in perfusion-related continuing education. In a contracted arrangement, specify who performs the assessment, against which protocols, and that the documentation is provided to the hospital.

What is the difference between a Standard and a Guideline in the AmSECT document? AmSECT defines a Standard as a practice, technology, or conduct of care that institutions shall meet, while Guidelines describe what should be done. The distinction matters for contracting, because the Standards are already written in mandatory language and translate directly into obligations, while Guidelines represent recommended practice that a hospital may choose to require but should not describe as a requirement.

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