Transplant Performance Improvement Steering Committee
August 28, 2013
1600-1730
Hartzler Conference Room
TOPIC
WHO
OBJECTIVES
Call to Order
Approval of minutes
OPO Donor Report
OPO Donor Stats Report
Administrative
Liver – CMS Approval
CMS Audit occurred Aug. 7-9
Update on Transplant Nephrologist
UNOS desk review of Liver & Renal programs
UNOS will complete a desk review in 9 months
regarding our deficiencies from UNOS 2012
audit.
Quality Assessment and
Performance
Improvement (QAPI)
EDIT Update
Quality Updates:
CMS Survey Changes –Focused QAPI Survey
 What to know about QAPI this quarter!
8/27 Organ Turndown Analysis Webinar
Current Quality Projects
 Streamlining Timestudy Process
 Cardiac, Renal, and Liver program
workflow (identify PI opportunities)
 On-going data entry (database & UNOS)
 Monthly chart audits
 Form revisions
 Abdominal Tx specific d/c instructions
 Kidney PI – MD Communication
 Kidney -LD orders, consent, and followup
 Kidney – Pt. Follow-up process
 Kidney – Protocol book revision
 Kidney – Post Pt. Endocrine Follow-up
Process
 Liver preparation for CMS audit
Next Steps


Policies, Procedures, and
Guideline Review
Regulatory Changes on
the Horizon
 UNOS
 CMS
Reports from Program
Level QAPI meetings
SRTR Report
Review Dashboards
 Clinical Outcomes
 Documentation
Compliance
 Contract Services
Performance
Tx QAPI Unplanned
Event Review
Liver Chart Standardization
MAHI Tx Clinic Storage Area
Reorganization (TJC)
 Cardiac PI- Donor Decline
 EDIT Database Prep
 Social Work Housing Project
 Transplant SW & Financial Risk
Assessment Tool
 Kidney Call process
 Completed Database Source
Documentation
No new policies for review at this time.
UNOS Webinar Review
 UNOS Public Comment Review of Policy
Re-write
Upcoming CMS CoP education
Liver - CMS Audit, Education Classes
Heart – 600th Tx
Kidney – Referring MD Communication,
inpatient eval
Rolling data spreadsheet
SRTR Education
CUSUM Reports
Liver
Heart
Kidney
CMS QAPI Measures
Review graft or patient losses
 Reviewable Event Log
 Kidney- XX, YY
 Cardiac- AA, BB
Multidisciplinary Report
Hospital Administrative
Report
New Business
Adjourn
5S/CVICU/East 9 Updates
Pharmacy Update
Dietary Update
Anesthesia Update
Hospital Quality Updates
Infectious Disease Update
 Post-Tx Follow-up for Recipients of High
Risk Donors
Updates
Upcoming meetings: November
27th (may change?), February 26th
2014
MEMBERS
Frederic Regenstein MD-Liver Medical Director ,Co-Chair
A Michael Borkon MD-Cardiac Surgical Director
Henry Randall MD-Renal/Liver Surgical Director
Andrew Kao MD-Cardiac Medical Director
Thomas Crouch MD-Renal Medical Director
Michelle Haines MD-Liver Anesthesia Director
Charles Vossler MD-Anesthesiologist MOR
Beth Lee – Clinical Director, Patient Care Services
Paul Jost MD-Infectious Disease Transplant Liaison
Debbie White-Chief Nursing Officer
Angela Locke- Clinical Director, Patient Care Services
Nancy Long- Transplant Administrator
Julie Quirin- SLH CEO
Amy Nachtigal – SLH CFO
Regrets:
Amy Cirese –Renal CNM
Kathy St.Clair-Cardiac CNM
Jamie Bartley-Liver CNM
Jacki Jackson-Transplant Quality Manager
Jeannie Terrell-Transplant Quality Analyst
Brynn Callahan – Transplant Quality Analyst
Lisa Heck – Transplant Compliance RN
Mary Reffett – Transplant Compliance RN
Kensey Gosch-Transplant Statistician
Mark Woods-Clinical Pharmacy Coordinator
Dennis Beers-Senior Quality Director
Brad Simmons-SLH COO
Tamara Adams – Manager, Clinical Nutrition Services