HRSA Transplant Center Growth and Management Collaborative: Best Practices Evaluation Report - September 2007

On its own, institutional vision and commitment to transplantation is not enough to achieve effective or successful growth of a transplant program with expected or higher than expected patient and graft survival outcomes. Another critical component is creating and supporting a collaborative and rewarding work environment to attract and retain highly dynamic, committed, and skilled specialists in transplantation.

Across all of the transplant centers visited, the concept of having a “dedicated team” composed of transplant surgeons, physicians, nurses, coordinators, social workers, financial managers and coordinators, medical specialists (e.g., infectious disease physicians, anesthesiologists, etc.), administrative staff, and allied health staff was noted as an essential and necessary component to having a successful transplant program. At all of the centers, this team is built and organized around proactive, committed, experienced, and high-performing surgeons and physicians who have a passion for building and growing the transplant program.

In order to be successful, these proactive and high-performing surgeons and physicians need to be supported by a talented and experienced multi-disciplinary team of nurses, coordinators, social workers, financial managers and coordinators, medical specialists, administrative staff, and allied health staff. Each team member possesses a unique set of skills, expertise, and knowledge that is needed to comprehensively treat transplant patients. Unlike other patients, transplant patients require life-long care, and their needs and treatment course vary from one phase of the transplant continuum to another (i.e., pre-transplant, peri-transplant, and post-transplant). Therefore, it is essential to recruit, train, and retain transplant team members that are specialized, dedicated, and committed to transplantation.

Given the multi-disciplinary nature of transplantation, a collegial, non-hierarchical team approach to care is necessary. At the transplant centers visited, all staff members work together as an integrated team toward the common goal of providing the best possible patient care. This culture of teamwork is evidenced by the involvement of all transplant team members in both patient care decisions and discussions about program improvements. However, in order for a collegial, non-hierarchical team environment to exist, it must be fostered and reinforced by every team member, especially the transplant program’s top surgical and physician leadership.

Exhibit 4 summarizes the three key change concepts and related action items that correspond with Strategy/Driver 2: Dedicated Team.

Exhibit 4:
Strategy/Driver 2: Summary of Key Change Concepts and Action Items

Key Change Concept 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.

Across all of the transplant centers visited, it was noted that the first step to creating a dedicated transplant team is to hire a committed and proactive surgeon and/or physician around which to organize the team. This surgeon or physician must be aligned with the institution’s vision to build and grow the transplant program.

Most centers recruit experienced surgeons and physicians from other centers. However, given the limited pool of experienced and proactive transplant surgeons and physicians, some centers use their residency and fellowship training programs to “grow their own.” In either case, these surgeons and physicians have a passion for, commitment to, and focus on building and growing transplantation. Their commitment is characterized by a willingness to take calls from their OPOs at all hours, to pursue donor information from the OPO, to be open to accepting grey area donor offers, to travel to examine potential organs, to devote extensive time to managing organs that may be suitable for transplantation, to be available to answer questions from other transplant team members 24 hours a day, and to work on the cutting edge to integrate new technologies. These surgeons and physicians do not view transplantation as one of their interests, but rather, as their sole focus and passion.

Action Items

• 2.1a: Recruit proactive, experienced, and high-performing surgeons and physicians with a passion for, commitment to, and focus on growing transplantation. All of the transplant centers visited noted that a necessary ingredient to building, growing, and maintaining a high volume transplant program is recruiting proactive and experienced surgeons and physicians who have a passion for and commitment to growing transplantation. These surgeons and physicians are the “engines of growth” for the program and set the tone for expansion.
  
  
  
  • In 2004, after hiring outside transplant experts to conduct a review of the transplant center, the Cleveland Clinic Board of Trustees made a commitment to growing its liver transplant program. In order to grow the program, the hospital decided to hire a proactive surgeon to head the liver program. This surgeon developed a business plan with ambitious targets for growing the program over 3 years. Under his leadership, as well as that of a new Department Chair, the center reached its goals. The center grew from 40 transplants in 2003 to 92 in 2004 and 122 in 2005.
    
    
    
  • At the University of California, San Francisco, several transplant staff were recruited from the University of Minnesota, including the current Chair of the Department of Surgery and the Chief of the Division of Transplantation. The intent of these hires was to bring-in experienced and proactive surgeons and physicians to grow the institution’s liver transplant program. One year following their recruitment, the liver program more than doubled its number of transplants from 39 in 1988 to 89 in 1989.
    
    
    
  • The addition of a young, emerging surgeon allowed New York-Presbyterian Hospital/Weill Cornell to greatly expand the number of kidney transplants it performed, growing from 101 procedures in 2004 to 175 in 2005 and 238 in 2006, including a 771 percent increase in the use of ECD organs.
    
    
    
  • At Duke University Medical Center, both the heart and lung transplant programs are led by proactive and experienced surgeons with a passion for transplantation. These surgeon leaders trained at Duke and have remained there since to practice medicine and conduct research. For the lung program, the current Surgical Director of the program started in the late 1990s. During this time, the number of lung transplants increased from the 30s to the 50s. For the heart program, the current Surgical Director joined the program in 2000, and from 1999 to 2000, the number of heart transplants more than doubled from 24 to 52.
    
    
    
  • At the Hospital of the University of Pennsylvania (HUP), the liver transplant program is led by innovative and experienced surgeons with a clear vision and commitment to transplantation. Both of the program’s surgical leaders were recruited from the University of California, Los Angeles in 1995 to help grow the program. Under their leadership, the liver transplant program at HUP has achieved steady growth through two main strategies: extensive outreach to community physicians to increase referrals for transplantation and thoroughly evaluating and finding a suitable candidate for every organ offer, including ECD and DCD organs. As a result of these practices and the commitment and dedication of these two surgeons, the liver program has grown from performing 19 transplants in 1994 to 47 in 1995 and 115 liver transplants in 2006.
    
    
    
  • The lung program at the Hospital of the University of Pennsylvania understands the importance of organizing around not only skilled and dedicated surgeons, but also skilled and dedicated physicians. In the initial stages of building the lung program, the hospital realized that in order to effectively manage the increase in volume, it needed to hire a skilled transplant pulmonologist to complement the work of its skilled transplant surgeon.
    
    
    
• 2.1b: Maintain selective and competitive residency and fellowship programs to attract, train, and recruit emerging talent. Given the limited pool of proactive, experienced, and high-performing transplant surgeons and physicians, some of the transplant centers visited use their residency and fellowship training programs to “grow their own” talent. By having selective and competitive residency and fellowship programs, centers are able to attract, train, and recruit strong candidates that are likely to grow into future leaders for their programs.
  
  
  
  • The Mayo Clinic recognizes the importance of identifying and recruiting surgeons and physicians who are skilled and have the entrepreneurial spirit to build and grow a transplant program. To help accomplish this, the Mayo Clinic maintains rigorous and competitive residency and fellowship programs to attract and retain emerging talent. Specifically, the transplant center actively seeks surgeons and physicians who will dedicate themselves to patient care, will thrive in a collaborative environment, and have the intellectual curiosity to further the transplant field through academic research.
    
    
    
  • To assist with recruitment, several of the San Francisco-area transplant centers, including the University of California, San Francisco, California Pacific Medical Center, and Stanford hire surgeons and physicians who have been trained at their institutions. The centers’ residency and fellowship training programs serve as a vetting mechanism to ensure the competencies of potential staff.

  
  Key Change Concept 2.2: Recruit, train, and retain program staff that are specialized, dedicated, and committed.

It is not enough to organize a transplant team around proactive and committed surgeons and physicians. Although surgeons and physicians can catalyze a growth spurt, in order to sustain a successful transplant program, surgeons and physicians need to be supported by a talented and experienced multi-disciplinary team of nurses, coordinators, socials workers, financial managers and coordinators, medical specialists, administrative staff, and allied health staff that are specialized, dedicated, and committed.

The transplant centers visited generally reported a dual approach to staffing their transplant teams. One prong of this approach involves active recruitment and retention of staff. Recruitment may involve hiring staff from other transplant centers, who can introduce new expertise and energy to the transplant program. Once hired, retention efforts focus on ensuring that current staff members remain with the transplant program, thus increasing tenure, reducing interruptions caused by training new staff, and allowing cohesive, longer term relationships among staff to develop.

The other prong of this staffing approach involves maximizing the efficiency of operations within the transplant program, which often entails adopting specialized roles for staff and continual training in transplantation. Across the transplant centers visited, various levels of specialization and dedication were observed throughout the transplant continuum, including: 1) staff focused exclusively on transplantation, 2) staff focused on one organ-specific transplant program, 3) further specialization within organ-specific programs to individual roles in the transplant process, and 4) staff dedicating a discrete portion of their time to transplantation or one organ-specific transplant program. In addition, in order to help maintain skill level and competencies, staff training is provided on a regular basis at most transplant centers visited. Given the complexities of transplantation, specialization is often required to produce strong clinical outcomes. As one hospital CEO noted, “There are fewer surprises when experienced staff perform transplants and treat pre- and post-transplant patients.”

Action Items

• 2.2a: Have transplant program staff (e.g., nurse coordinators, financial coordinators, socials workers, administrators) that work exclusively on either transplantation or one organ-specific transplant program. (e.g., liver). In order to develop staff expertise in transplantation, several of the transplant centers visited have transplant staff that work exclusively on either transplantation or one organ-specific transplant program. Within organ-specific programs, further specialization may occur (e.g., kidney transplant coordinators may be sub-specialized into pre-coordinators, post-coordinators, and living donor coordinators). Through repetition of tasks, staff members are able to build skill, competency, and confidence in their transplant duties, which allows them to anticipate and preempt potential problems and complications. While other fields of medicine do not always require such professional focus, the complexity and risks of transplantation necessitate this level of specialization, dedication, and commitment.
  
  
  
  • Most of the liver transplant staff at the Mayo Clinic, including surgeons, physicians, and nurse coordinators, work exclusively on transplantation, rather than including it among other responsibilities. The Mayo Clinic even employs specialized liver transplant anesthesiologists and a nephrologist who focuses exclusively on liver transplant-related kidney conditions. This commitment and dedication to transplantation, which must be respected by supervisors and colleagues, allows staff to develop expertise in transplantation and to focus on building and growing the program.
    
    
    
  • At Clarian Health, surgeons focus on transplantation on a full-time basis. Across all transplant programs, surgeons, rather than transplant coordinators, receive the initial calls for organ offers, and a dedicated procurement surgeon, rather than a fellow, recovers all organs. This level of expertise reduces the decision-making time needed for organ acceptance and recovery and significantly contributes to the efficiency of the entire transplant process.
    
    
    
  • At the University of California, San Francisco (UCSF), certain transplant team members have organ-specific duties. For example, given that the social and emotional needs of patients vary from one type of transplant to another (e.g., kidney patients may have to deal with weight issues, while liver patients may have histories of substance abuse), each transplant program at UCSF has dedicated social workers that work exclusively for that organ program. They provide organ-specific assistance to patients before, during, and after the transplant procedure. This type of specialization allows social workers to effectively assist patients with various social issues that may arise during the transplant process and help to ensure that patients are both physically and emotionally prepared for transplantation and life following the procedure.
    
    
    
  • The transplant center at New York-Presbyterian Hospital/Columbia University and New York-Presbyterian Hospital/Weill Cornell feature surgeons, physicians, nurses, coordinators, social workers, pharmacists, and administrative assistants who work exclusively in their organ-specific transplant program. Many of these staff members’ responsibilities are further subdivided. For example, transplant coordinators include pre- and post- coordinators, as well as living donor coordinators. The heart transplant program at Columbia University even has a dedicated procurement team, complete with a dedicated perfusionist.
    
    
    
• 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 transplantation or one organ-specific transplant program. Given that some transplant programs do not have the volume to support staff that focus exclusively on transplantation or on one organ-specific transplant program, several of the transplant centers visited have staff members that dedicate a discrete portion of their time to transplantation. Although not exclusively focused on transplantation, these staff members are still able to develop experience and expertise in transplantation.
  
  
  
  • At the Hospital of the University of Pennsylvania, medical specialists, including infectious disease physicians, pathologists, and psychiatrists, dedicate a discrete proportion of their time to transplant medicine in order to develop subject expertise.
    • The New York-Presbyterian Hospital has staff members who, while not exclusively transplant-oriented, dedicate a discrete proportion of their time to the transplant center. This includes psychiatrists, infectious disease specialists, immunologists, and financial and strategic planners.
    
    
    
• 2.2c: Educate transplant center staff about innovations in transplantation through weekly staff meetings, annual retreats and other venues. Transplantation is a young, evolving field with new practices, innovations, and technologies emerging on a regular basis. In order to be a high-performing transplant center, staff members need to be kept apprised of these advances in the field so they can be applied in practice. To accomplish this, several of the transplant centers visited conduct weekly and/or annual staff meetings to discuss innovations in transplantation and how the program may benefit from these innovations.
  
  
  
  • The Cleveland Clinic’s lung transplant program holds weekly staff meetings and annual (soon to be semi-annual) off-campus retreats to educate staff about innovations in the field, featuring internal and external presenters reviewing their research. For example, at a recent retreat, an advanced practice clinical coordinator from a California OPO was brought in to present on best practices in donor management.
    
    
    
  • The lung transplant team at Duke University Medical Center participates in off-site monthly retreats to discuss the field of lung transplantation and to learn how new devices, techniques, pharmaceuticals, and other innovations can contribute to and enhance the team’s work.
    
    
    
• 2.2d: Send teams of surgeons, physicians and coordinators to visit other high-performing centers to observe their practices first-hand. One way to effectively grow a transplant program is to go and observe practices at another high-performing transplant center. During its expansion phase, the Cleveland Clinic sent its liver transplant team, including surgeons and nurse coordinators, to another high-performing liver transplant center in order to observe their best practices firsthand. The visit helped the team identify practical strategies for effectively managing a growing program.
  
  
  
• 2.2e: Provide regular training sessions for recovery unit nurses on caring for transplant patients immediately after surgery. In almost all of the transplant centers visited, the recovery unit nurses do not exclusively treat transplant patients, but rather, have transplant patients included among all of their other patients. To help develop and maintain recovery unit nurses’ competencies to care for transplant patients who usually have very specific needs, centers provide them with regular transplant-specific training sessions and courses.
  
  
  
  • At University of Washington Medical Center, recovery unit nurses who care for liver and lung post-transplant patients receive training and guidance from the transplant surgeons on how to most effectively treat patients. Given that these recovery unit nurses do not focus exclusively on transplant patients, regular training is necessary to maintain their skills and competencies. The training provided by the transplant surgeons include review of immunosuppression protocols and protocols on how to get patients off sedation and how to properly extubate patients. In addition, during bedside rounds, the surgeons will work with the recovery unit nurses on deciding the best treatment plan for the patients and how to provide that care.
    
    
    
  • To help ensure that newly hired recovery unit nurses are skilled and trained to take care of transplant patients, the University of California, San Francisco provides an extensive, 2-week training course that includes transplant-specific classes for all recovery unit nurses prior to their start in the hospital.
    
    
    
• 2.2f: Conduct regular educational sessions about transplant services for all hospital staff. Transplantation in any institution is not isolated just to the transplant center. It touches and impacts several departments within the hospital, including laboratory, anesthesiology, radiology, finance, etc. For example, a liver transplant patient may require chemical dependency counseling from a psychiatrist. Therefore, for transplantation to be successful, all hospital staff should be regularly educated about transplant services. At University of Washington Medical Center, transplant surgeons and physicians provide ongoing education to update hospital staff about changes and innovations related to transplantation. These educational sessions take place during inpatient rounds, bi-weekly clinical issues meetings, as well as during hospital grand rounds.
  
  
  
• 2.2g: Offer financial and non-financial retention incentives to transplant program staff. Because the success of a transplant program is due in large part to the experience, expertise, and established relationships of its team members, it is important for transplant centers to retain their transplant program staff. In addition, extensive resources and time are required to recruit, hire, and train staff. Payers also place a premium on continuity of transplant teams and look to staff retention as evidence of a successful program. In areas with several competing centers and programs, retention is even more important. For example, in the San Francisco, Philadelphia, and New York areas, proactive retention practices and policies are necessary because of the frequent “raiding” of staff by local and regional competitors. Across the transplant centers visited, various financial and non-financial incentives are offered to help retain staff and keep them satisfied, especially given that “it’s easier to retain than re-train.”
  
  
  
  • At the University of California, San Francisco (UCSF), surgeons are offered financial incentives for taking on challenging cases and for performing research. While such a system has the potential to devolve into intense intramural competition, this tendency is tempered by the program’s cooperative and collaborative environment. Although financial incentives are not extended to nursing and allied health staff, other retention-oriented policies have been enacted, including staff vesting after 5 years. However, perhaps the most powerful driver of retention is the environment in which staff members work. Nurses, coordinators, and allied health staff at UCSF repeatedly cited the respect and autonomy afforded to them by hospital and program leaders as a major contributor to retention.
    
    
    
  • To help retain staff, surgeons and physicians at Clarian Health are reimbursed through a private practice model, rather than fixed salaries. This model provides them with financial incentives to proactively grow the transplant program, while, at the same time, meeting quality standards. For other staff types, competitive salaries, as well as educational and training opportunities for career development (e.g., paying for certification classes) help keep staff at Clarian.
    
    
    
• 2.2h: Organize staff schedules to avoid staff burn-out. Given the unpredictable nature of when transplants may occur (including in the middle of the night) and the life-long follow-up of transplant patients, staff members can easily be overextended and burnt-out. To avoid this, some of the transplant centers visited organize staff schedules in such a way as to provide downtime and changes in pace, environment, and job responsibilities.
  
  
  
  • California Pacific Medical Center is committed to avoiding overexertion and burnout among its transplant nephrologists. The center has established a rotating schedule for the nephrologists so that they have changes of pace and downtime in their schedule. The physicians’ schedule is organized around four 3-week rotations in the following areas: inpatient service, outpatient clinic and lab reviews, community outreach (e.g., traveling to satellite clinics), and administrative work.
    
    
    
  • The post-kidney coordinators at the Hospital of the University of Pennsylvania rotate between inpatient and outpatient service, which allows them to gain experience and expertise in a diversity of tasks. This model of nursing care helps to avoid staff burn-out by providing the coordinators with regular changes in patients, environment, and responsibilities.
    
    
    
• 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. Back in 2000, the kidney program at Stanford lost two of its surgeons. This led to a substantial drop in the number of patients on their waitlist. Several patients were taken off the list because the program was not large enough. There even were rumors that Stanford no longer had a kidney transplant program. As a result, Stanford has had to rebuild their kidney waitlist since 2000. The experience disclosed the vulnerability of the transplant program and underscored the importance of having a contingent “Plan B” or succession plan in place to ensure program continuity following staff turnover. Stanford now tries to have in place for each transplant program an alternate surgeon and physician within the transplant team (usually more junior team members) who could be OPTN-designated if the program were to lose a key doctor, so that it could continue despite the loss and until such time that a replacement is found. California transplant centers like Stanford face high housing costs, which serve as an additional impediment to the recruitment of transplant surgeons and physicians who are already in short supply. Therefore, Stanford tries to be aware of any discontent among its transplant doctors and makes efforts to avert any plans they have to depart.
  
  
  

  Key Change Concept 2.3: Establish and live by a collegial, non-hierarchical team approach to quality care.

In a field that integrates so many types of specialized providers and staff, a collegial, non-hierarchical team environment is essential. Given the multi-disciplinary nature of transplant medicine, collaboration and communication among various hospital departments and staff members is necessary for providing patients with the best possible care. Each transplant team member possesses a particular area of expertise and knowledge, which must be sought and considered when making patient care decisions.

At all of the transplant centers visited, program teams comprise a multi-disciplinary group of surgeons, physicians, nurses, coordinators, social workers, financial managers and coordinators, medical specialists, administrative staff, and allied health staff. Each staff member is treated with respect by his/her colleagues, and traditional rivalries (e.g., between surgeons and physicians) and hierarchies (e.g., between physicians and nurses) are eschewed, while cooperation and collaboration are encouraged. In order for such an environment to prevail, it must be reinforced by the transplant program’s leadership. This is often accomplished through deed rather than decree, in an effort both to empower and influence staff.

Action Items

• 2.3a: Have multi-disciplinary transplant teams (e.g., surgeons, physicians, nurse coordinators, social workers, financial coordinators, pharmacists, anesthesiologists, infectious disease physicians, etc.). At all of the transplant centers visited, transplant teams were composed of a multi-disciplinary group of staff, including surgeons, physicians, nurses, coordinators, social workers, financial managers and coordinators, pharmacists, anesthesiologists, infectious disease physicians, etc. Each staff member possesses a particular area of expertise needed to effectively treat and care for transplant patients.
  
  
  
• 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. Because each transplant team member has a particular area of expertise, it is important to actively consider the input and advice of all transplant team members when patient care decisions are made. This not only ensures the best treatment course for the patient, but also helps to build teamwork and morale by making each staff feel like a valued member of and important contributor to the team.
  
  
  
  • A broad array of staff is represented at New York-Presbyterian Hospital’s patient selection meetings. Staff who regularly attend the meetings include surgeons, physicians, pre- and post-transplant coordinators, social workers, and financial coordinators. At these meetings, the opinions of all staff types are actively solicited and considered accordingly. In addition, in order to provide comprehensive care, New York-Presbyterian Hospital practices collaborative rounding, including surgeons, physicians, nurses, social workers, care coordinators, nutritionists, and physical therapists. Such collaboration is facilitated by well-defined roles. Staff members respect each other’s areas of expertise and know to whom to turn for guidance and assistance on particular issues.
    
    
    
  • Stanford’s heart transplant team holds weekly patient selection meetings that feature involvement from more than 50 surgeons, cardiologists, nurses, coordinators, social workers, infectious disease physicians, and allied health staff. In these meetings, patients and practices are discussed, and a wide variety of opinions are considered so as to comprehensively inform patient care decisions.
    
    
    
  • At University of Washington Medical Center, staff from across the transplant continuum of care, including surgeons, physicians, nurses, social workers, and dieticians all round together as a team. During rounds, input is actively sought from all staff members.
    
    
    
• 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). In order to remain a high-performing transplant center, programs need to regularly review and re-evaluate their practices and processes and make improvements as necessary. Because each transplant staff member plays an important role on the team and contributes to the program’s success, all transplant team members need to be involved in this process.
  
  
  
  • At Duke University Medical Center, monthly off-site retreats are held with the entire lung transplant team, including surgeons, transplant pulmonologists, nurse coordinators, social workers, pharmacy, infectious disease, and administration to discuss changes to the program and ways to improve it (e.g., reviewing and updating protocols and policies). During these retreats, input from all team members is sought and actively considered.
    
    
    
  • On an annual basis, the lung program at the Cleveland Clinic hosts department-wide retreats in which staff discuss and set goals for the program, establish the program’s research agenda, review treatment protocols and donor acceptance criteria, discuss ways of improving the program’s workflow, and discuss barriers in lung surgery and ways to overcome these barriers, including the use of new technologies. The retreats are attended by more than 60 staff members and serve as a morale and team-building booster.
    
    
    
• 2.3d: Encourage the surgical and physician leadership to abide by and reinforce a collegial, team approach to care. Having a collegial, team environment does not just happen at most transplant centers because it is the rule; it needs to be embodied as part of the center’s culture. At several of the transplant centers visited, it was indicated that for a collegial, non-hierarchical team environment to truly exist, it must be fostered and reinforced by the transplant program’s top surgical and physician leadership.
  
  
  
  • The collegial, non-hierarchical environment at New York-Presbyterian Hospital was established by the transplant center’s leadership and is reinforced by all staff levels. An “open door” policy exists within the transplant programs; however, in order for a collegial environment to work effectively, communication must be proactive, with staff, especially the program leadership, reaching out to their colleagues.
    
    
    
  • Duke University Medical Center staffs its transplant programs with multi-disciplinary teams who make decisions about patients jointly. A social worker defined the atmosphere as “everyone has a special role, and everyone’s voice is heard.” Each specialist is an important contributor to the transplant team, and this collegial approach is maintained and reinforced by the surgical and medical leadership of the transplant program.
    
    
    
  • At the University of California, San Francisco, there is a very collaborative environment where “doctors and nurses work together” to provide the best possible patient care. Nurses feel comfortable asking doctors questions about the management of patients. This type of collegial, team approach comes from the top leadership. The Chair of the Department of Surgery promotes this type of environment, which trickles down to the residents, fellows, and surgical and physician leadership of the transplant programs.
    
    
    
• 2.3e: Have surgeons and physicians accessible to all transplant team members 24 hours a day. In transplantation, as with several other medical disciplines, patient care is on-going and never takes a break. Sometimes, patient care decisions have to be made in the middle of the night in order to optimize patient outcomes. Therefore, having access to transplant surgeons and physicians 24 hours a day to either make or inform these decisions is necessary. The liver and lung transplant coordinators at University of Washington Medical Center report that the transplant surgeons and physicians make themselves available to discuss cases and answer questions at any time of the day. This level of access to the transplant surgeons and physicians has helped the nurses effectively manage patient care in programs that have grown substantially over the past few years.