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

In order to maintain their high-performing transplant center status, the transplant centers visited repeatedly stressed the importance of aggressively managing program performance outcomes. According to the centers, transplant program performance and growth can be optimized through the implementation and use of protocols, research and innovation, and data-driven quality improvement. Collectively, these components create a pathway for transplant programs to become leaders in the field of organ transplantation by increasing the number of transplants performed and the patients served, while maintaining high quality outcomes.

Protocols contribute to increased transplant volume and quality outcomes by providing a standardized, efficient, and high quality way of delivering transplant services and care. As one transplant nephrologist noted, “Best practices are protocol-driven and cannot exist in chaos.” Because transplant programs so often grow before resources are expanded, protocols are essential to ensure that a busy staff is capable of effectively handling increased patient volume. Protocols also help to provide clarity and understanding among staff of their roles and responsibilities and what is expected of them. In addition, protocols allow providers to teach effectively, review outcomes, increase efficiency, ensure safety, and practice evidence-based care. Protocols can help to not only increase transplant volume, but also to improve outcomes. For example, pre-transplant protocols can expedite the process of getting patients on the waitlist, while effective immunosuppression protocols can help to optimize post-transplant graft and patient survival.

In addition to advancing the field of transplant medicine, clinical research and innovative practices increase transplant volume and growth in several ways. For example, at some centers, there is a direct link between increased transplant volume in recent years and new and emerging practices in organ and patient acceptance, as well as in pre- and post-transplant clinical care. Volume is also driven by patients who are eager to get treated at a hospital that is performing cutting-edge research, which may positively impact their care, outcomes, and quality of life. Similarly, payers prefer to contract with centers that are involved in research and developing innovative solutions to transplant care.

Across all of the transplant centers visited, the collection, tracking, and monitoring of transplant program data is a major component of quality improvement. Through systematic reviews of program data, transplant programs are able to recognize trends, explain outliers, and most importantly, identify problem areas and implement appropriate process improvement strategies.

Exhibit 8 summarizes the three key change concepts and related action items that correspond with Strategy/Driver 6: Aggressive Management of Performance Outcomes.

Exhibit 8:
Strategy/Driver 6: Summary of Key Change Concepts and Action Items

Key Change Concept 6.1: Implement protocol-driven, standardized care.

Across several of the transplant centers visited, the development, maintenance, and use of protocols has been instrumental in the centers’ abilities to increase transplant volume and growth, without compromising patient and graft survival outcomes, by providing a standardized and efficient way of providing transplant services and care. Protocols allow for clear decision making and also assist in academic research because with protocols, one variable can be changed while all others are held constant, thereby allowing outcomes to be reliably assessed and compared.

The type of protocols that are used varies across transplant centers. For example, some of the centers have detailed, step-by step protocols for every aspect of transplant care, from pre-transplant care to post-transplant follow-up. Other centers have developed protocols for referring physicians in the community to ensure consistency of pre- and post-transplant care provided outside the transplant center. Protocols also exist for patients to help them manage their own post-transplant care. However, regardless of the type of protocol, transplant centers recognize the need to adapt to new and emerging practices and regularly modify and update protocols when clinical evidence supports such changes.

Action Items

• 6.1a Develop and maintain current evidence-based protocols for pre-transplant care, organ procurement, peri-transplant care, and post-transplant care. To ensure standardized, efficient, and consistent care for all patients across the transplant continuum, centers have developed protocols for every phase of transplantation, including pre-transplant care, organ procurement, peri-transplant care, and post-transplant care. This detailed set of written clinical protocols facilitates consistent application of evidence-based care.
  
  
  
  • At Mayo Clinic, Web-based peer-reviewed protocols for standardized pre-transplant, peri-transplant, and post-transplant care are accessible to transplant program staff at all three sites (i.e., Rochester, Jacksonville, and Scottsdale/Phoenix) on a 24-hour basis (e.g., from their desks to patient exam rooms and the hospitals). Protocols are developed through teamwork and consensus among transplant clinicians and are updated annually based on current data and research. Examples of protocols include: monitoring recurrent disease after kidney transplantation; monitoring glucose levels in potential living kidney donors; and management of post-transplant anemia in transplant patients.
    
    
    
  • Through the use of step-by-step protocols, the liver transplant procedure has been highly standardized among the surgeons at Clarian Health, making them basically interchangeable. As a result, the time needed to perform a liver transplant procedure has decreased significantly from 6 hours to about 2 hours, allowing up to five transplants to be performed a day.
    
    
    
  • New York-Presbyterian Hospital has developed several protocols for various transplant practices and procedures that have contributed to the growth and expansion of its transplant programs. Examples of protocols include:
    
    
    
    • Columbia University’s kidney program has developed a desensitization protocol featuring plasmaphoresis and low-dose intravenous immunoglobulin, which has had a 95 percent success rate.
      
      
      
    • Weill Cornell’s kidney team has developed protocols for positive cross-matches, ABO incompatibility, and for transplanting older patients.
      
      
      
    • The heart program at Columbia University has created a manual that contains protocols for screening candidates that have been referred for transplantation; coordinating patients’ evaluation appointments; and immunosuppression regimens.
      
      
      
    • Weill Cornell’s kidney program has formalized its acceptance criteria for ECD and DCD organs, pediatric organs, and dual-organ transplant procedures. These protocols allow surgeons and transplant coordinators to make appropriate, accurate, and timely decisions regarding organ acceptance.
      
      
• 6.1b: Develop, maintain and adhere to protocols for pre- and post- transplant care for referring physicians in the community. Because several patients are cared for by their referring physicians before and after the transplant procedure, the University of Washington Medical Center’s liver transplant program has developed pre- and post-transplant care protocols for community referring physicians on how to care for and manage their patients. The protocols include guidelines for required labs and patient education. This ensures consistency and homogeneity in care and management across transplant cases, even when care is being provided outside the transplant center by other physicians.
  
  
  
• 6.1c Develop, maintain and adhere to protocols for patients to help them manage their own care. Because patients play an important role in managing their own care, the University of Washington Medical Center has developed protocols for patients immediately post-transplant. These protocols, entitled “care maps,” help patients understand their post-transplant care after leaving the intensive care unit. Printed on laminated paper and posted on the wall of each patient’s room, care maps include specific instructions for patients to follow to ensure timely discharge from the hospital. For example, the liver transplant patient care map includes patient activities and milestones in the areas of physical activity, daily living, diet, education, and discharge planning over a 7-day period. Care maps increase patient and family involvement with the plan of their care by allowing them to pro-actively monitor their progress and understand the milestones they need to achieve to be discharged from the hospital.
  
  
  
• 6.1d Be organized and prepared to modify protocols when clinical evidence supports such changes. Although transplant staff members are expected to closely adhere to protocols, the protocols themselves are not static; their development is an ongoing, organic process that is informed by research evidence, staff input, and best practices from other organ transplant programs. When modifications are made to protocols, staff members are encouraged to question the changes in order to understand why the changes were made and how best to care for patients.
  
  
  
  • At Mayo Clinic, transplant protocols are reviewed during the annual summit of its three sites. The protocols are reviewed and updated to ensure consistency of care among staff in Rochester, Jacksonville, and Scottsdale, and to reflect the latest evidence on and innovations in transplant care across the pre-, peri- and post-transplant continuum.
    
    
    
  • Duke University Medical Center holds monthly retreats for its lung transplant program, where staff members discuss programmatic changes and review clinical and financial data in order to make informed changes to protocols and policies. For example, at a recent monthly retreat, clinical and financial data on the use of Plavix, an anticoagulant agent in stent patients, were reviewed. It was determined that more research needs to be conducted to determine the effects of Plavix in these patients and to develop an appropriate anticoagulation protocol.
    
    
    

  Key Change Concept 6.2: Be on the cutting edge: be a research leader and innovator.

Research and innovation serve the dual purpose of advancing the field of transplantation and driving transplant volume and growth by pushing the envelope in terms of transplant procedures and practices and by attracting patients, payers, and staff. Given the young field of transplantation, conducting research to advance the field is critical. Research allows more to be discovered about transplantation, which impacts both transplant volume and outcomes. At all of the transplant centers visited, staff members are encouraged to actively keep abreast of the latest research and innovations in transplantation through regular review of literature, attending professional conferences, taking continuing medical education courses, and participating in other professional development activities.

At some of the centers visited, the increase in the number of transplant procedures performed in recent years can be directly traced to research findings and innovative solutions in transplant practices. For example, by expanding the boundaries of organ acceptance and transplantation criteria to include less than perfect organs (e.g., organs from older donors, DCD and ECD organs) and unconventional transplant candidates (e.g., HIV+ patients), these centers have been able to grow their transplant programs, while maintaining expected or higher than expected quality outcomes.

In addition to serving patients with unmet needs, these pioneering transplant centers have raised the profile of their institutions, resulting in increased payer referrals. Patients are also attracted to centers that are performing cutting-edge research and engaging in innovative transplant practices. Lastly, research and innovation also play an important role in recruiting and retaining staff by keeping them interested and excited about their work.

Action Items

• 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.). The Cleveland Clinic focuses on using evidence to diminish risk aversion in transplantation. By keeping abreast of research and innovations in transplantation, the transplant team is able to take calculated risks more effectively. The Clinic provides transplant staff continuing education opportunities through weekly meetings and annual retreats to ensure that everyone is up-to-date on advances in the field.
  
  
  
• 6.2b: Contribute to the knowledge base about transplantation – research, innovate, evaluate and disseminate findings to the field. Several of the transplant centers visited have been able to achieve significant transplant growth, while maintaining expected or higher than expected patient and graft survival outcomes, by developing innovative transplant procedures and practices and conducting research to improve transplant outcomes. By pushing the envelope through innovation and research, these transplant centers are viewed as leaders in the field.
  
  
  
  • At Hahnemann University Hospital, innovative practices have helped to drive transplant volume and growth in its kidney program. Since the arrival of an experienced transplant surgeon in 1991, the following innovative practices have been adopted:
    
    
    
    • Starting in 1992, more recipients over the age of 60 were transplanted using organs predominantly from older donors.
      
      
      
    • In 2000, protocols for steroid cessation after 2nd day post-transplant were implemented to improve patient outcomes.
      
      
      
    • In 2001, HIV+ recipients began receiving transplants.
      
      
      
    • Beginning in 2002, organs were recovered and transplanted from donors who experienced acute renal failure.
      
      
      
    • In 2003, the program began accepting organs from donors who had recovered from cancer in their lifetime (pending autopsy/body scan).

  As each new technique was implemented, patient and graft survival outcomes were reviewed to ensure safety and efficacy. These innovative practices comprise about 40 percent of the kidney transplants currently being performed at Hahnemann. As their effectiveness has been demonstrated, some of Hahnemann’s innovative practices have been more broadly adopted by other centers. To help disseminate its findings to the field, Hahnemann has published several articles on its research results, including one on the safety and efficacy of steroid-free immunosuppression protocols after kidney transplantation and another on the successful transplantation of kidneys from donors with acute renal failure.

  • Transplanting patients with liver malignancy and performing “domino” liver transplant procedures are some examples of innovative procedures being conducted at Mayo Clinic. Domino transplant procedures aim to maximize utilization of livers and involve two patients who both need a new liver. The liver from the first patient suffering from a genetic degenerative disorder is removed and transplanted into the second patient. The first patient then receives a cadaveric liver. The liver from the first patient, once removed, functions normally and allows the second patient to live for a few decades without experiencing any symptoms of the disease. The first “domino” liver transplant procedure in Arizona was performed at the Mayo Clinic in Phoenix in 2003.
    
    
    
  • New York-Presbyterian Hospital’s transplant programs are currently engaged in a number of cutting-edge activities. For example, its kidney transplant program offers a comprehensive program for incompatible living donors and potential recipients, as well as laparoscopic living donor nephrectomies. In addition, rather than performing a risky and uncomfortable biopsy, Columbia University’s heart transplant program has developed a non-invasive blood test to screen for rejection, while Weill Cornell’s kidney transplant program utilizes a molecular assay via urinalysis. New York-Presbyterian Hospital also engages in research to advance the field of transplant medicine. For example, immunosuppression therapy has been one area of intense research. Researchers have worked to develop new drugs and regimens and to tailor regimens to specific patients. In reviewing immunosuppression protocols, Columbia University’s kidney transplant program has been able to stop steroid treatment by the 3rd day post-transplant without compromising outcomes.
    
    
    
  • At Duke University Medical Center, conducting research to advance the state of transplant care is paramount to the institution’s mission. Given the complexities of lung transplantation and that the long-term outcomes for lung transplant patients are less favorable than for other transplant procedures due to post-transplant complications, the Medical Director of the lung transplant program is currently conducting ongoing clinical research studies and clinical trials to design and implement better strategies to prevent post-transplant infections such as with cytomegalovirus (CMV), and other viral and fungal pathogens. The diverse research program at Duke seeks ultimately to improve outcomes for all transplant recipients. In addition to conducting research, Duke is also an innovator in transplantation, which has resulted in more transplant volume without sacrificing high quality outcomes. For example, in 2001, its heart failure service line developed a Left Ventricular Assist Device (LVAD) program. LVADs are often used to ”bridge” heart failure patients to transplantation, thus saving patients from death on the waitlist. An LVAD patient is considered 1-B status on the waitlist and automatically receives 30 days of 1-A waitlist status. Usually, LVAD patients are transplanted during this 30-day window. Since the LVAD program began, the heart program has been able to maintain sicker patients on its waitlist and has conducted 5 to 10 more heart transplants per year without sacrificing outcomes.
    
    
    
  • The University of California, San Francisco has used innovation to expand its transplant recipient pool by performing transplant procedures on older patients, as well as HIV+ patients. The kidney transplant program has also offered innovative and creative solutions for increasing living kidney donations. These solutions include paired exchanges (also known as “family swaps”), exchanges to the list, and giving IVIG therapy for ABO incompatibility. About 10 percent of living kidney donor transplants in 2004 were as a result of these innovative options.
    
    

  Key Change Concept 6.3: Implement data-driven continual quality improvement.

According to the transplant centers visited, the aggressive collection and review of transplant program data plays a vital role in having a successful transplant program. Careful monitoring of outcomes and benchmarks allows transplant programs to identify areas for improvement and to remedy problems before they become serious and compromise patient care.

Across the centers visited, quality improvement and management takes on many different forms. Some transplant centers monitor quality through a formal structure such as a quality improvement committee, while others have staff members that either are fully committed or dedicate portions of their time to quality improvement reviews and initiatives. In addition, some centers hold regular meetings among transplant program staff to review the program’s performance data. One common activity among all of the centers visited is the collection and review of program data and measures on a regular basis to identify areas for program improvement. As transplant patients become more informed consumers through the review of OPTN and SRTR program data, continual quality improvement will become increasingly important.

Action Items

• 6.3a Establish a quality improvement committee that is responsible and accountable for reviewing and monitoring the transplant program’s performance. Some of the transplant centers visited have established formal quality improvement committees charged with developing transplant program quality improvement plans, monitoring outcome measures, and overseeing performance improvement initiatives. Having a formal committee enhances the institution’s commitment to delivering high quality care and streamlines institutional resources directed towards quality improvement functions.
  
  
  
  • Each of the three hospitals that comprise Clarian Health has a Quality Improvement Committee, which is responsible for developing an annual quality plan, overseeing performance improvement teams, and evaluating progress and status of key quality management initiatives for all of the hospital’s service lines, including transplantation. The three Quality Improvement Committees report to Clarian Health’s Quality Council, which in turn, reports to the institution’s Board of Directors’ Committee on Quality and Patient Care.
    
    
    
  • At Mayo Clinic, a Quality Improvement Committee (i.e., the Transplant Center Quality Initiative Program) oversees all quality management functions of the transplant center and its programs. The Committee is led by the Medical Director of the liver transplant program and enlists the help of the medical and surgical directors of all the transplant programs in developing and monitoring quality improvement reviews and initiatives.
    
    
    
• 6.3b Hire a full-time transplant program quality specialist. In 2005, acknowledging the complexities of transplant services, the hospital leadership at Clarian Health supported the transplant administrator and clinicians in hiring a full-time transplant quality specialist who could focus on continuous quality improvement. This decision also was based on recognizing the importance of monitoring quality given the recent increase in transplant volume at Clarian. The responsibilities of the quality specialist include producing and monitoring transplant-specific quality measures with targeted goals against which performance is tracked and accountability is established (e.g., patient and graft survival rates, waitlist mortality, diabetes inpatient glycemic control); conducting 1-day seminars on quality improvement processes and activities for all levels of transplant staff; and working with transplant staff to identify areas for quality improvement, with the goal of completing one PDSA (Plan, Do, Study, Act) process improvement model per transplant program per month.
  
  
  
• 6.3c Have staff members dedicate portions of their time to quality improvement reviews and initiatives. At Mayo Clinic, transplant program staff members dedicate a discrete portion of their time to quality improvement activities. This practice allows all staff to play a role and stay involved in quality improvement reviews and initiatives on a regular, continual basis. With a discrete portion of their time dedicated to quality improvement activities, staff members are prevented from having to choose between monitoring quality outcomes and attending to clinical tasks.
  
  
  
• 6.3d Strive to achieve near-perfect (e.g., “6 sigma”) quality in eliminating transplant errors and optimizing patient care. New York-Presbyterian Hospital uses the “6 sigma” quality measurement and improvement designation for staff training and certification in order to minimize errors and optimize patient care. Reporting to the Chief Quality Officer, a Master Black Belt oversees a quality management unit composed of nine transplant quality management specialists with nursing backgrounds and a performance improvement specialist with a master’s degree in nursing. The quality management unit establishes standardized protocols for measuring clinical outcomes, survival rates, patient satisfaction, and efficiency, and also collects and reports transplant data that is submitted to OPTN. The addition of quality management specialists with nursing, rather than non-clinical, backgrounds has resulted in 100 percent compliance with reporting of OPTN data.
  
  
  
• 6.3e Establish organ-specific measures and goals against which performance is measured and accountability is established. Several of the transplant centers visited have established organ-specific measures to track and review, as well as goals against which performance is measured and accountability is established. By having organ-specific measures and goals, these centers and programs are able to closely monitor their performance and make changes whenever necessary to enhance center and program outcomes.
  
  
  
  • At the Hospital of the University of Pennsylvania (HUP), the transplant center leadership regularly reviews quarterly reports generated by the Department of Clinical Effectiveness and Quality Improvement (CEQI), which consist of real-time, organ-specific outcome measures and serve as a “report card” for monitoring the clinical and operational effectiveness of each transplant program. The measures include a combination of internal and National standards and can be customized to include a variety of outcomes as requested by transplant program leadership. Some specific examples of measures include patient and graft survival rates, inpatient length of stay, 30-day and 90-day inpatient and emergency room readmission rates, infection rates, patient satisfaction measures, utilization of services (e.g., lab tests, number of units of blood transfusions per patient, pharmacy costs) and operational effectiveness (e.g., number of FTEs, occupied beds, case mix index). In addition to monitoring these measures, HUP also tracks “reciprocal measures” for certain metrics. The measures do not have to be “reciprocals” in the true sense of the word, but there does have to be a cause and effect relationship that is measurable, which would allow clinicians to assess and monitor the interaction of the two measures and to better understand the dynamics of the interaction. By understanding the interaction, clinicians are better equipped to make effective clinical decisions. Some examples of reciprocal measures include length of stay reductions and readmission rates. It is important to monitor these two measures together because a reduced length of stay that results in an increase in readmission rates is problematic. Another example of reciprocal measures is changes or reductions in induction therapy and treatments for rejection. Induction therapy is intended to suppress the immune system so that the body is less likely to reject an organ. However, immune suppression has its own side effects, so it is important to maintain a balance. A third example of reciprocal measures is discharge rates for pre-heart transplant candidates on an ACE (angiotensin-converting enzyme) inhibitor or ARB (angiotensin receptor blocker) and readmission for heart failure. Both ACE inhibitors and ARBs are given to heart failure patients to lower blood pressure and fluid retention, thereby reducing workload on the heart. If pre-transplant candidates with bad or failing hearts are discharged and prescribed drugs such as these, clinicians hope they are not readmitted to the hospital with heart failure. The transplant leadership at HUP monitors outcome measures and their reciprocal metrics to examine current practices, to identify any problem areas, and to guide program improvement efforts.
    
    
    
  • Clarian Health generates and tracks monthly reports of more than 35 transplant-specific quality measures with targeted goals for performance improvement. The report includes measures of patient and graft survival rates, waitlist mortality, other clinical indicators such as diabetes inpatient glycemic control, and measures of patient satisfaction and experience of care. Individual mortality data are discussed with all levels of transplant program staff during patient selection meetings. Measures that are significantly below their targeted goals are analyzed extensively to identify root causes, so that appropriate changes can be made to improve performance.
    
    
    
  • The Cleveland Clinic has developed a real-time, computerized dashboard of clinical and financial data for transplant leaders, department chairs, and clinicians. These data allow the programs to monitor their performance on a daily basis. The dashboard includes measures of cost per case, length of stay by DRG and physician, and wait time for care. The transplant administrator at Cleveland Clinic relies on these data to help inform clinical decisions.
    
    
    
• 6.3f Collect and review the program’s data and measures on a regular basis. All of the transplant centers visited regularly collect and review data on various transplant program outcome measures and use the data to monitor and improve quality of care.
  
  
  
  • At Mayo Clinic, the Transplant Center Quality Initiative Program generates a monthly Outcomes Report and a quarterly Performance Report for the program directors of all the transplant programs. The monthly Outcomes Report includes a list of all newly reported graft losses and patient deaths within 1 month and 1 year of transplantation. Within 30 days of receiving this report, program directors are required to submit a written narrative review of all the reported graft losses and patient deaths, including a root cause analysis. The quarterly Performance Report lists 1-month, 1-year, and 3-year patient and graft survival rates for each transplant program and compares these data to the risk-adjusted SRTR National survival rates. Programs with survival rates at or above their corresponding Nationwide SRTR averages are invited to present best practices to their colleagues in order to promote center-wide quality improvement initiatives. Programs with survival rates below their corresponding Nationwide SRTR averages are expected to perform a root cause analysis and to develop a quality improvement action plan within 60 days.
    
    
    
  • At the University of California, San Francisco, all hospital departments and programs, including transplantation, are asked to identify outcome measures, which are approved by the institution’s Clinical Performance Improvement Committee and used to monitor quality of patient care. The Committee tracks these data and generates quarterly reports of the measures for each hospital department and program. Transplant program measures include the number of transplant procedures, organ acceptance rates, average number of days from referral to first appointment, median number of days from referral to first appointment, 1-year graft survival rates, and 3-year graft survival rates.
    
    
    
• 6.3g Conduct regular meetings among transplant program staff to review the program’s performance data and to identify areas for improvement. At most of the centers visited, data collected on transplant program performance are regularly reviewed by transplant program leadership and staff during multi-disciplinary meetings and are reported to hospital executive leadership through formal presentations and discussions. This process allows integration of all levels of staff in the quality improvement process and provides an opportunity for staff to provide input on monitoring and addressing various aspects of the transplant programs’ clinical, operational, and financial performance.
  
  
  
  • At Hahnemann University Hospital, transplant outcome data, such as the number of patients on the waitlist, number of transplant procedures performed, and patient and graft survival rates are reviewed at bi-monthly transplant meetings attended by all members of the kidney transplant team. During these meetings, follow-up improvement strategies to address poor outcomes are identified and implemented as necessary. These transplant outcome data are also presented to the hospital executive leadership at the semi-annual Surgical Performance Improvement meetings, which are attended by the Vice President of the medical staff, senior members of the Department of Surgery, and senior hospital administration staff. In addition, the Chief of the Division of Transplantation and the Director of Transplantation track data on sources of transplant referrals and set targeted goals for future outreach and marketing activities.
    
    
    
  • At Clarian Health, transplant outcome data are continually monitored through several formal processes including:
    
    
    
    • Annual presentation of the transplant quality dashboard to the institution’s Quality Council.
      
      
      
    • Review of transplant outcome measures, such as length of stay (LOS), readmission rates, returns to the operating room, inpatient mortality, and intensive care unit LOS twice a year at patient selection meetings attended by transplant surgeons, physicians, social workers, transplant coordinators, nurse managers, registered dieticians, and transplant pharmacists.
      
      
      
    • Review of quality of life and patient satisfaction survey results, Clarian’s SRTR transplant outcome measures, and Clarian’s transplant data published by the University HealthSystem Consortium (UHC) four times a year at patient selection meetings.
      
      
      
    • Continuous review of transplant center volume statistics for referrals, evaluations, listings, and transplant procedures for each program, and presentation of these data at patient selection meetings every quarter.
      
      
      
  • At New York-Presbyterian Hospital, hospital and transplant program staff are integrated into the transplant quality management process through various mechanisms. For example, during multi-disciplinary weekly meetings of physicians, surgeons, transplant coordinators, administrators, social workers, and quality management staff, quality-related transplant outcome measures (e.g., graft losses and patient deaths), SRTR survival rates, and compliance with OPTN data collection and reporting requirements are discussed. These same quality management issues are discussed during bi-weekly management meetings with the vice presidents of the finance, legal, and quality departments. In addition, “Transplant Quality Matters,” a newsletter that includes the latest transplant-related quality news, is disseminated to all hospital staff on a regular basis.
    
    
    
• 6.3h Track and review program data to enhance clinical, financial, operational, and staff performance. Some of the sites visited integrate data from a variety of internal and external clinical and administrative sources and use these data as benchmarks to monitor quality and improve clinical, financial, and operational functions of their transplant programs.
  
  
  
  • At Duke University Medical Center, there is a systematic, regular process for reviewing data to improve clinical, operational, and financial performance. Measures include, but are not limited to, readmission rates, returns to the operating room, mortality rates, referral to evaluation time, patient satisfaction, and revenue. The transplant program teams review this information during monthly operational meetings and retreats to present trends, explain outliers, and identify areas for improvement. Sometimes, meetings may result in revised protocols and care guidelines or cost containment efforts. In addition, because transplantation is one of the nine clinical service units at Duke, the transplant administrator is required to track and report transplant program data to the hospital executive leadership every quarter in the context of the hospital’s balanced scorecard. The four categories of indicators on the scorecard include: 1) Quality and Patient Safety, 2) Customer Satisfaction, 3) Finances, and 4) Work Culture.
    
    
    
  • University of Washington Medical Center (UWMC) uses clinical, administrative, and organizational outcomes data from a variety of sources, such as the University HealthSystem Consortium (UHC) benchmarks and real-time data from internal billing and financial databases, to monitor and improve quality and costs of its transplant programs. For example, to improve quality, data have been used to: 1) review patient mortality rates associated with transplants from expanded criteria donors, 2) establish standardized protocols for immunosuppressive therapy, and 3) make decisions on organ acceptance criteria. To improve costs of its transplant programs, UWMC conducted a side-by-side comparison of data on different drugs prescribed across physicians in order to identify the most cost-effective drugs and to make appropriate modifications to prescription drug protocols.
    
    
    
• 6.3i Review and monitor transplant outcomes data to assess the safety and effectiveness of new/emerging practices (e.g., use of marginal organs). At some of the transplant centers visited, a structured system of monitoring outcomes allows transplant programs to assess the safety and efficacy of new and unconventional clinical practices, such as the use of marginal organs. By aggressively evaluating the effect of various practices on pre-determined benchmarks, their effectiveness can be determined.
  
  
  
  • Duke University Medical Center’s lung program monitors the outcomes associated with transplants from extended criteria donors and has been able to demonstrate that these outcomes are not necessarily worse than outcomes from transplants associated with standard criteria donors. In addition, the program tracks outcomes from certain high-risk recipient groups such as older patients to determine whether they are comparable with outcomes of younger patients. These data are shared with all surgeons and physicians in the lung program, allowing them to raise the threshold for rejecting less than optimal organs and to adopt less restrictive patient acceptance criteria.
    
    
    
  • At the University of California, San Francisco, the Director of Quality Improvement and the Risk Management Department collaboratively monitor outcomes associated with the safety and effectiveness of unconventional practices, such as the use of marginal organs. When issues are identified, they work with the transplant program leadership to review clinical practices and make changes as necessary.