HRSA Transplant Center Growth and Management Best
Practices Initiative Change Package Document
| Strategy/Driver |
Key Change Concepts |
Action Items for Testing1
(C=Clinical; A=Administrative) |
1. Institutional
Vision and Commitment:
Hospital leadership demonstrates a commitment to making transplantation
an institutional priority and to assuring the necessary resources
to make this vision a reality. |
1.1 Establish transplant as a strategic priority
|
1.1a Establish transplantation as a priority
service for the hospital and set goals for transplant program
growth. (Stanford, CC, UWMC, Mayo) (A)
1.1b Identify and commit resources needed to successfully grow
the transplant programs (e.g., surgeons, transplant coordinators,
dedicated ORs, office space, dedicated recovery unit). (UWMC,
CC, Mayo, others) (A)
1.1c Conduct regular review of transplant center performance
data by transplant center and hospital leadership (e.g., CEO,
COO, CFO, CMO, medical school dean). (UWMC) (A) |
| 1.2 Develop and implement business/strategic
plan to secure institutional resources |
1.2a Identify targets, goals, and the resources
required to grow the transplant program. (CC, UCSF, Stanford)
(A)
1.2b Demonstrate the clinical, economic, and non-monetary benefits
of transplant. (HUP, NYPH, CC) (A)
1.2c Develop impact plans to help anticipate and forecast the
downstream effects of the addition of new personnel and technologies.
(Stanford, UCSF, NYPH) (A) |
| 1.3 Actively educate internally about goals,
expected outcomes and accountabilities |
1.3a Educate hospital executives, department
chairs and other institutional leaders (e.g., governing board)
about how transplant is a unique area of service that requires
significant investments in nurse coordinators, information technology
and other resources |
| 1.4 Commit to providing a comprehensive, multi-disciplinary
approach to the full continuum of transplant care
|
1.4a Provide care across the continuum of transplantation.
(All) (C&A)
1.4b Offer transplant services as part of end-stage disease
care. (HUP, CC) (C&A)
1.4c Provide care across specialties (i.e., across organ types)
(e.g., liver transplant patients may develop kidney problems
post-transplant and require care from a nephrologist). (HUP)
(C&A) |
| 1.5 Organize transplant services into a service
line |
1.5a Integrate all transplant services into a
single service line with designated budget and decision-making
authority. (UWMC, CPMC) (A)
1.5b Work with hospital leadership to establish a governance
and oversight structure for transplant service line that facilitates
joint decision-making among surgeons and physicians. (UWMC)
(A)
1.5c Establish direct line of report for transplant center staff
to hospital leadership (e.g., COO). (UWMC, CPMC) (A) |
| 2. Dedicated Team:
Create and support a collaborative and rewarding work environment
to attract and retain highly dynamic, committed and skilled
specialists in transplantation. |
2.1 Organize around and empower committed surgeons
and physicians who are aligned with the institution’s vision
to build and grow the transplant program |
2.1a Recruit aggressive, experienced, and high-performing
surgeons and physicians with a passion for, commitment to, and
focus on growing transplantation. (All) (A)
2.1b Maintain selective and competitive residency and fellowship
programs to attract, train, and recruit emerging talent. (Mayo)
(A)
|
| 2.2 Recruit, train, and retain program staff
that are specialized, dedicated, and committed |
2.2a Have transplant program staff (e.g., nurse
coordinators, financial coordinators, socials workers, administrators)
that work exclusively on either transplant or one organ-specific
transplant program. (e.g., liver) (Mayo, UCSF, Stanford, CPMC,
UWMC, NYPH, HUP, CHOP, Clarian) (C&A)
2.2b For staff that are not exclusively transplant-focused (e.g.,
surgeons, physicians, anesthesiologists, infectious disease
physicians, pharmacists, psychiatrists) have a discrete proportion
of their time dedicated to transplant or one organ-specific
transplant program. (Mayo, UCSF, Stanford, CPMC, NYPH, HUP,
Clarian) (C&A)
2.2c Educate transplant center staff about innovations in transplant
through weekly staff meetings, annual retreats and other venues.
(CC) (C&A)
2.2d Send teams of surgeons, physicians and coordinators to
visit other high-performing centers to observe their practices
first-hand. (CC-liver) (C&A)
2.2e Provide regular training sessions for recovery unit nurses
on caring for transplant patients immediately after surgery.
(UWMC, UCSF) (C&A)
2.2f Conduct regular educational sessions about transplant services
for all hospital staff. (UWMC) (C&A)
2.2g Offer financial and non-financial retention incentives
to transplant program staff. (UCSF, Stanford, HUP, Clarian)
(A)
2.2h Organize staff schedules to avoid staff burn-out. (CC,
CPMC, Stanford) (A)
2.2i Recognize that transplant program success can be vulnerable
to the loss of just one or two key staff, and establish a contingent,
current “Plan B” or succession plan. (UWMC, Stanford) (A) |
| 2.3 Establish and live by a collegial, non-hierarchical
team approach to quality care |
2.3a Have multi-disciplinary transplant teams
(e.g., surgeons, physicians, nurse coordinators, social workers,
financial coordinators, pharmacists, anesthesiologists, infectious
disease physicians, etc.). (All) (C&A)
2.3b Actively consider the input of all transplant team members,
including surgeons, physicians, nurse coordinators, social workers,
dieticians, and other allied health staff, in patient care decisions.
(Mayo, UWMC, Duke, UCSF, Stanford, NYPH, Clarian) (C)
2.3c Involve entire transplant team, including surgeons, physicians,
nurse coordinators, social workers, pharmacists, infectious
disease physicians, and administration, in periodic (e.g., monthly)
meetings and dedicated events (e.g., annual retreats) to discuss
the program and ways for improving it (e.g., reviewing protocols
and policies, discussing new technologies and pharmaceutical
therapies in transplantation). (Duke, CC, Clarian, NYPH) (C&A)
2.3d Encourage the surgical and physician leadership to abide
by and reinforce a collegial, team approach to care. (Duke,
Stanford, UCSF) (C&A)
2.3e Have surgeons and physicians accessible to all transplant
team members 24 hours a day. (CPMC, UWMC) (C&A) |
| 3. Aggressive Clinical Style:
Assure program growth through advanced clinical practices in
organ and patient acceptance and waitlist management and collaborate
with referring physicians and OPOs on optimal care for donors
and patients. |
3.1 Create high threshold for rejecting organ
offers and potential recipients |
3.1a Involve transplant surgeon in organ offer
prior to turndown. (UCSF – heart, UWMC – liver, others) (C)
3.1b Reject organ offers only after you have confirmed that
a suboptimal organ is not viable by visualizing (inspecting
in-person) organs or confirming inconclusive or prohibitive
test results. (Duke, UWMC, CC, others) (C)
3.1c Work with OPO donation coordinators to “tune up” offered
organs that are suboptimal yet have potential to be viable for
transplant. (UWMC, others) (C)
3.1d Continually take measured, evidence-based steps to push
the envelope on organ acceptance criteria, including accepting
ECD and DCD organs. (UCSF, Stanford, UWMC, Mayo-Jacksonville,
HUP, Hahnemann, CC, others) (C)
3.1e Plan transplant program budgets that account for an inevitable
proportion of “dry runs” (e.g., traveling to visualize an organ
and returning without one). (CC, Duke, others) (A)
3.1f If an offered organ is a potential match for someone on
your list, do not reject it simply because a surgeon from another
center has to procure it; trust your colleagues at other centers.
(CC-pancreas) (C)
3.1g Monitor and work consistently on lowering ischemic and
operating times to increase the viability and to reduce recipient
complications. (Mayo Jacksonville) (C)
3.1h In conjunction with OPO and other regional transplant centers,
use data on whether organs that were rejected by the center
were accepted for transplant elsewhere to assess whether the
center’s organ acceptance criteria and practices are too conservative.
(Mayo Jacksonville) (C&A)
3.1i Based on existing and emerging evidence, expand the envelope
for accepting higher risk recipients (e.g., older patients,
patients critically ill in the ICU, experiencing multiple system
failure, suffering from nutritional failure, with HIV, and with
body mass indices in excess of 40). (Stanford, UCSF, UWMC, Hahnemann,
NYPH, others) (C)
3.1j Treat reversible contraindications for transplant in candidates
not initially selected. (UCSF) (C)
3.1k Expand living donor procedures, including living liver
donor surgeries, through alternative/novel solutions such as
paired exchanges (also known as “family swaps”), exchanges to
the list, immunoglobulin therapy in the event of a positive
cross-match, and desensitization in the event of ABO incompatibility.
(CC) (C)
3.1l Review patient acceptance criteria regularly to determine
if they are appropriate in light of emerging evidence about
new therapies. (HUP) (C)
3.1m Institute no absolute “rule-out” characteristics; a patient
should be evaluated as a whole, and, if possible, matched to
an appropriate organ. (Duke, UWMC) (C)
3.1n Use an intention-to-treat analysis to inform organ (and
patient) acceptance criteria. Consider how a patient would fare
without an organ when deciding whether or not to accept a marginal
organ. (NYPH) (C)
3.1o When offered a heart or lung, ask about the availability
of the other thoracic organs, as they have often not been placed
and may match a patient on the waitlist. (CC) (C) |
| 3.2 Maintain preparedness by building, managing
and optimizing your waitlist |
3.2a Monitor and continuously work on reducing
time from referral to evaluation and from evaluation to listing
of patients. (Mayo, CC, UWMC-liver) (C&A)
3.2b Monitor the medical, financial and social status of all
patients on the waitlist and help them to intervene where feasible
to overcome barriers to transplant. (All) (C&A)
3.2c Schedule periodic “top-of-the-list” meetings to review
the status of patients closest to transplant to ensure that
all tests are complete and all information is up-to-date. (CPMC,
NYPH, others) (C&A)
3.2d Know your waitlist; ensure that surgeons who receive organ
offers have access to up-to-date, accurate information about
waitlisted patients. (Mayo, others) (C)
3.2e Build and maintain the waitlist to a size that is manageable,
yet includes sufficient patient diversity to enable identifying
appropriate matches for most offers of viable organs. (Many)
(C)
3.2f Develop a defined process for ECD consent. (C) |
| 3.3 Reach out and collaborate with referring
community and professional staff |
3.3a Develop and disseminate protocols for pre-
and post-transplant care for referring physicians in the community
(UWMC) (C)
3.3b Encourage transplant surgeons and physicians to personally
reach out to referring physicians in the community to educate
them about pre- and post-transplant care and to facilitate collaboration
on lifelong care of recipients post-transplant. (Phila., CC–lung,
UWMC-lung) (C)
3.3c Provide 24/7 phone lines through which referring physicians
can access a physician or coordinator to ask questions about
pre- and post-transplant care for their patients. (UWMC, Stanford)
(C)
3.3d Send annual report cards to referring centers and physicians,
highlighting outcomes and the contributions of specific referring
parties. (CC) (A) |
| 3.4 Partner with OPOs to implement best practices |
3.4a Collaborate with OPO donation coordinators
and critical care specialists on best practices in managing
organ donors from declaration of death to organ recovery; provide
regular refresher training and training for new coordinators.
(UWMC) (C) |
| 3.5 Actively market program to increase referrals
and organ offers |
3.5a Market to referring providers through general
education sessions about transplantation in the community. (CPMC)
(C&A)
3.5b Reach out to referring physicians in the community to increase
awareness about transplant as an appropriate treatment modality
for challenging/difficult cases about which there may be misconceptions
that transplant is still experimental. (CC) (C&A)
3.5c Encourage transplant surgeons and physicians to reach out
personally to community providers to establish relationships,
build trust, and communicate that the transplant center is committed
to partnering with them to care for their patients (HUP, UWMC,
Mayo) (C&A)
3.5d Send kidney outreach teams to community dialysis centers
to reach patients who may be eligible for transplant, but have
not been referred to a transplant center for evaluation; create
and distribute self-referral forms for dialysis patients. (CPMC,
Hahnemann, Clarian) (C&A)
3.5e Educate OPOs outside service area about the center’s organ
acceptance criteria to boost organ imports. (UWMC) (C&A) |
| 4. Patient and Family Centered
Care: Establish institution-wide practices, systems
and mechanisms to organize care around the needs of patients
and families in an effort to provide the best possible care
to every patient and family everyday. |
4.1 Remove patient access barriers and streamline
workflow to provide more efficient care |
4.1a Make the opportunity to transplant available
to patients by accepting referrals that other centers do not
and by safety expanding patient acceptance criteria. (UWMC,
Duke, UCSF, Hahnemann) (C&A)
4.1b Be available and responsive to patients 24/7. (Stanford,
UWMC, CPMC) (C&A)
4.1c Establish satellite clinics in outlying communities where
patients can receive pre- and post-transplant care. (CPMC, UCSF)
(C&A)
4.1d Offer clinic hours for pre- and post-transplant care five
days a week and provide care after-hours. (Mayo, NYCP) (C&A)
4.1e Rotate transplant physician schedules to ensure that there
is always a specialist available to answer questions from nurse
coordinators and to avoid burnout. (CPMC, CC) (C&A)
4.1f Use transplant-specific information technology systems
to allow physicians and staff 24/7, off-site access to patient
information to allow for continuous care coverage and monitoring
(CPMC)
4.1g Integrate the organ transplant program so that physician
offices, outpatient clinic rooms, and inpatient beds are in
proximity. (Mayo, HUP) (A)
4.1h Make the patient evaluation and selection process as easy
and efficient as possible from the patient’s perspective. (UWMC,
Mayo, CC, HUP, Hahnemann) (C&A)
4.1i Maintain contact with patients for life: before, during,
and after the transplant. (Mayo, Duke, Stanford) (C&A) |
| 4.2 Educate patients and their “families” early
and often |
4.2a Provide “drip education” for patients, ensuring
they are educated health consumers. (Stanford, UWMC, Clarian,
Duke, UCSF) (C&A)
4.2b Offer 24/7 telephone access to post-transplant coordinators
for all transplanted patients, donors and their families to
answer questions about treatment plans and complications. (UWMC,
CPMC) (C)
4.2c Provide on-line information for transplant patients and
their “families”, offering information in different languages
and modalities to ensure information is accessible for all education
levels. (CHOP) (A) |
| 4.3 Don’t forget the “family”: Involve and support
“families” throughout the entire transplant process. |
4.3a Create a “family”-friendly environment.
(CHOP) (C&A)
4.3b Provide affordable, on-site housing to pre- and post-transplant
patients. (Mayo, Stanford) (C&A)
4.3c “Normalize” transplant care by making patients feel at
home, even when they are in the most abnormal of circumstances.
(CHOP) (A) |
| 5. Financial Intelligence:
Achieve transplant program financial strength through
a detailed understanding of program finances, sound financial
management, and excellent payer relations. |
5.1 Track and understand your program finances,
reimbursement mechanisms, performance, and volume |
5.1a If possible, establish the transplant program
as a separate cost center. (UWMC, CPMC) (A)
5.1b Communicate with people who are responsible for finances
as well as other hospital departments to understand the “multiplier”
or “spillover” impact of transplant services. (Clarian, NYPH,
CC) (A)
5.1c Encourage open communication and collaboration among financial
staff, administrative staff, and clinicians to understand transplant
cost and revenue drivers, the clinical aspects of transplantation
that affect cost, and emerging clinical practices and technologies
that are affecting the field. (UCSF, Stanford, HUP, Clarian,
CC) (C&A)
5.1d Accurately prepare and understand Medicare cost reports
and involve clinical and other staff in ensuring that all Medicare
costs are recognized. (Clarian, UCSF, Stanford) (A)
5.1e Convene monthly or quarterly transplant revenue management
meetings with all staff involved in any part of transplant finances,
including the front-end and back-end staff (e.g., billing personnel,
patient financial services, financial coordinators, managed
care managers, transplant administrators). (UWMC, CC) (A) |
| 5.2 Negotiate payer contracts with awareness
of program strategy, finances, and strengths |
5.2a Model contracts and rates based on program
costs and actual patient resource use. (UWMC, Stanford, HUP,
CHOP, UCSF) (A)
5.2b Recruit dedicated, expert transplant contract managers
and dedicated and expert financial coordinators. (UCSF, Stanford)
(A)
5.2c Monitor shifts and changes in payer mix. (San Francisco,
Clarian) (A)
5.2d Monitor payer policies and annual coverage changes. (UCSF,
Stanford) (A)
5.2e Seek diverse payer mix to ensure that financial viability
of transplantation is not dependent on one payer.(UCSF) (A)
5.2f Leverage program strengths (e.g., quality outcomes, ability
to take on tough cases, transparent pricing, being one of few
transplant centers in the region) to negotiate payer contracts.
(HUP, UWMC, UCSF, CC, Stanford) (A)
5.2g Educate payers about program strengths and outcomes to
increase payer referrals. (Stanford, CC) (A) |
| 5.3 Develop and maintain constructive, mutually
beneficial payer relationships |
5.3a Make fairness an explicit aim in relations
with payers (e.g., communicate mistakes in payment to payers
even when they would have been financially advantageous to the
hospital). (Stanford) (A)
5.3b Provide predictable pricing to payers. (CC, HUP) (A)
5.3c Establish open, ongoing communication with payers and contact
them for multiple reasons, not just when there is a problem
(e.g., to let them know about new programs at the hospital and
new advances and practices in the transplant program). (UWMC,
Stanford, Clarian) (A)
5.3d Involve transplant program clinical staff in maintaining
relationships with payers. (CC) (C&A) |
| 5.4 Provide transplant-specific counseling and
coordination to patients and families |
5.4a Help patients with handling all transplant
financial matters and offer assistance with financing their
transplant services. (All) (A)
5.4b Help patients identify ways to fill gaps in their insurance
coverage, including switching health plans where appropriate
and feasible. (All) (A)
5.4c Assist patients with billing matters by being their liaison
to the hospital billing department. (Stanford) (A) |
| 6. Aggressive Management
of Performance Outcomes: Optimize transplant program
performance through the implementation and use of protocols,
research and innovation, and data-driven quality improvement
/performance. |
6.1 Implement protocol-driven, standardized care
|
6.1a Develop, maintain and adhere to current
evidence-based protocols for pre-transplant care, organ procurement,
peri-transplant care, and post-transplant care. (UWMC, Mayo,
others) (C)
6.1b Develop, maintain and adhere to protocols for pre- and
post-transplant care for referring physicians in the community.
(UWMC) (C)
6.1c Develop, maintain and adhere to protocols for patients
to help them manage their own care. (UWMC) (C)
6.1d Be organized and prepared to modify protocols when clinical
evidence supports such changes. (Mayo) (C) |
| 6.2 Be on the cutting edge: be a research leader
and innovator |
6.2a Don’t rely on personal experience alone;
keep up with research and innovations in transplantation through
regular review of literature and professional activities (conferences,
CME, etc.). (All) (C)
6.2b Contribute to the knowledge base about transplantation
– research, innovate, evaluate and disseminate findings to the
field. (UWMC-lung, Mayo, others) (C) |
| 6.3 Implement data-driven continual quality improvement |
6.3a Establish a quality improvement committee
that is responsible and accountable for reviewing and monitoring
the transplant program’s performance. (Mayo) (A)
6.3b Hire a full-time transplant program quality specialist.
(Clarian) (A)
6.3c Have staff members dedicate portions of their time to quality
improvement reviews and initiatives. (Mayo) (A)
6.3d Strive to achieve near-perfect (e.g., “6 sigma”) quality
in eliminating transplant errors and optimizing patient care.
(NYPH) (A)
6.3e Establish organ-specific measures and goals against which
performance is measured and accountability is established. (HUP,
Clarian, CC) (A)
6.3f Collect and review the program’s data and measures on a
regular basis.
(All) (A)
6.3g Conduct regular meetings among transplant program staff
to review the program’s performance data and to identify areas
for improvement. (NYPH, Clarian, Hahnemann) (A)
6.3h Track and review program data to enhance clinical, financial,
operational, and staff performance. (UWMC, Duke) (C&A)
6.3i Review and monitor transplant outcomes data to assess the
safety and effectiveness of new/emerging practices (e.g., use
of marginal organs). (UCSF, Duke) (C&A) |
1In
parentheses following each action item is a partial list of the
transplant centers at which these practices were observed. Abbreviations
include the following: “CC” refers to Cleveland Clinic; “UCSF”
refers to the University of California, San Francisco; “HUP” refers
to the Hospital of the University of Pennsylvania; “NYPH” refers
to the New York-Presbyterian Hospital/Columbia and Cornell; “UWMC”
refers to the University of Washington Medical Center; “CPMC”
refers to the California Pacific Medical Center; and “CHOP” refers
to the Children’s Hospital of Philadelphia. Unless otherwise noted,
“Mayo” refers to Mayo Clinic Rochester.
Back to: Transplant
Center Growth and Management Collaborative: Best Practices Evaluation
Report
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