Transplant Performance Improvement Steering Committee
August 28, 2013
1600-1730
XXX 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
Liver Medical Director ,Co-Chair
Cardiac Surgical Director
Renal/Liver Surgical Director
Cardiac Medical Director
Renal Medical Director
Liver Anesthesia Director
Anesthesiologist MOR
Clinical Director, Patient Care Services
Infectious Disease Transplant Liaison
Chief Nursing Officer
Clinical Director, Patient Care Services
Transplant Administrator
SLH CEO
SLH CFO
Regrets:
Renal CNM
Cardiac CNM
Liver CNM
Transplant Quality Manager
Transplant Quality Analyst
Transplant Quality Analyst
Transplant Compliance RN
Transplant Compliance RN
Transplant Statistician
Clinical Pharmacy Coordinator
Senior Quality Director
SLH COO
Manager, Clinical Nutrition Services