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

The first strategy/driver describes a factor that is fundamental to the success of a transplant center – vision and commitment from the institution. Organ transplantation is a special area of medicine that involves a wide range of hospital staff and resources, has relatively high resource needs and regulatory requirements, operates on an unpredictable schedule based on the availability of organs for transplantation, and that must run like a well-oiled machine when organs become available. Hospitals cannot dabble in organ transplantation; they must commit to it fully and provide the resources and support necessary for the transplant programs to be successful.

For many of the Nation’s hospitals and for all the hospitals visited over the course of this study, the benefits, both to the institutions and the patients they serve, far outweigh the risks and challenges of providing organ transplant services. In fact, the 15 hospitals featured in this study view transplantation as one of their institutions’ priority service areas and all have established and successfully worked toward goals of growing their programs. In some cases, the vision and leadership for growing transplant programs has emanated from the top with senior hospital executives identifying an opportunity to grow the program and seeking out surgeon and physician leaders who share their goal and can develop and implement a strategy to make it happen. In other cases, the transplant program administrators and leaders have built institutional support for transplantation by building a case for the value of transplant services to patients as well as the hospital.

The first three key change concepts in this section describe how successful transplant programs establish a vision, goals, and targets for their programs and identify and secure institutional support for resources, policies, and practices that they will need to realize their vision and accomplish their goals. The fourth key change concept describes an approach to care to which transplant centers and hospitals should commit. The final key change concept describes an organizational structure for transplant services that some of the high-performing transplant centers have implemented and which their staff believe has contributed significantly to their programs’ growth.

Exhibit 3 summarizes the five key change concepts and related action items that correspond with Strategy/Driver 1: Institutional Vision and Commitment.

Exhibit 3:
Strategy/Driver 1: Summary of Key Change Concepts and Action Items

Key Change Concept 1.1: Establish transplantation as a strategic priority.

All of the hospitals featured in this study have provided strong support to their transplant centers and several of them have even established organ transplantation as one of a handful of strategic priorities for their institutions. The prominence of transplantation within these hospitals reflects the life-saving or life-changing benefits that the hospitals perceive for the patients who will benefit from a new organ, as well as financial and other non-economic benefits that providing organ transplant services will confer on the institutions.

This key change concept describes how at these high-performing centers, transplantation has been established as a priority service area and how that message has been communicated internally within the institution to ensure that transplant services are prioritized. It also describes examples where hospitals have made significant investments in staffing and other resources in order to facilitate the growth of the transplant center or one of its transplant programs. In addition, examples are provided on how at some centers, there is an ongoing commitment to helping transplant programs achieve their goals among senior hospital executives and how they monitor their programs’ progress toward their goals on a regular basis.

Action Items

• 1.1a: Establish transplantation as a priority service for the hospital and set goals for transplant program growth. Many of the high-performing transplant centers visited enjoy strong support from the leadership of their hospitals. In fact, organ transplantation has been identified as one of a handful of “high priority” or “strategic priority” or “premier” service areas in many of these hospitals. The reasons that organ transplantation tends to garner this level of institutional support are numerous. In addition to being a relatively profitable service (though usually not the most profitable), organ transplantation is viewed as a prestigious area of medical care that is exciting for staff and elevates a hospital’s image as an institution that provides services that are beyond routine hospital care. One of the first steps for hospitals seeking to expand their transplant programs is to set goals for growing the programs. In the case of the high-performing centers visited for this study, these goals were established based on an assessment of the untapped opportunity in the hospital’s market environment, the competitive advantage of the transplant center, and its capacity for growth.
  
  
  • New York-Presbyterian Hospital³³ recognizes transplantation as one of its high priority service areas and establishes goals for growth and commits resources to it accordingly. The hospital established transplantation as a premier service because of the margins, prestige, publicity, and staff excitement it generates. As such, when transplant programs have grown and required additional resources, the hospital has been amenable to providing them. This support is also steady, which allows leaders of the transplant programs to comfortably forecast their budgets and expenditures.
    
    
  • The University of Washington Medical Center established organ transplantation as one of six strategic services, each of which would be structured as a separate service line with a direct line of report to the hospital administration. Hospital leadership worked with the center’s administrative and physician leaders to establish goals for growth based on an assessment of the opportunities in the region to expand the programs. One of the nurse coordinators at the center observed that it has been valuable to have institution-wide recognition of transplantation as a strategic priority because it reduces internal barriers to needed resources (e.g., operating room space).
    
    
• 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). Once hospitals have established organ transplantation as a strategic priority and established goals for growing their programs, a critical early step is identifying and committing the resources that will be required to enable the transplant programs’ growth. As the programs grow, the transplant center leadership and administrators should revisit these issues with the hospitals’ leaders on a frequent basis as additional needs are identified. At the high-performing transplant programs visited, these resources often included the hiring of a proactive transplant surgeon; adding staff capacity among transplant physicians, nurse coordinators, and other clinical and administrative staff; expanding office space; securing dedicated clinical space (e.g., ORs or outpatient clinic visit space); and investing in management information systems and other tools to help the programs run more efficiently.
  
  
  • In 2004, the California Pacific Medical Center determined that the capacity of its histocompatibility lab was becoming a limiting factor to the continued growth of its kidney transplant program. The lab technicians were overworked, often working until the middle of the night to complete their tests. The center compared its lab capacity and transplant volume to other centers around the country and confirmed that its lab was indeed under-resourced. Transplant center administrators compiled and presented comparative data on staffing capacities and lab volumes and presented these data to the hospital’s leadership. Persuaded that investing in an expansion of the lab would translate into better quality care and enable sustained growth of the transplant program, the hospital invested the resources to increase the staff capacity from 4.5 to 19 full-time employees.
    
    
  • When the University of Washington Medical Center recruited a new chair for its liver transplant program, the surgeon requested that the center demonstrate its commitment to growing the transplant program by establishing organ transplantation as a priority for OR space, anesthesia, nursing, and other resources to the extent that the center would be able to perform three or more liver transplants simultaneously at the center. Because transplant surgeries have a tendency to cluster at certain times of the day, a high volume center must be able to handle multiple transplants at a time. The hospital agreed and communicated this to the necessary department chairs and staff. Transplant center staff report that transplantation’s position as one of the six high priority service areas for the hospital has facilitated cooperation among other departments in accommodating this request and that on at least three occasions, the hospital has performed five liver transplant surgeries simultaneously. Transplant center staff are currently working with the hospital to secure dedicated OR space for transplant surgeries.
    
    
• 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). All of the transplant centers visited stressed the importance of monitoring and tracking clinical, operational, and financial data on a regular basis and using that information to drive improvements. Centers use the data to establish goals and priorities for the transplant programs, identify areas where performance can be improved, and to monitor progress toward achieving goals over time.
  
  
  • At the University of Washington Medical Center, transplant center financial and outcomes data are reviewed regularly by transplant center administrators, clinical staff, and hospital executives. Part of the charge of the transplant center’s Operating Committee, which is made up of transplant surgeons physicians, nurses, and administrators, is to review clinical and operational data on a regular basis and to use it to identify areas where performance could be improved and to monitor progress toward improvement goals over time. The center’s clinical and operational performance data are reported up to an Oversight Committee that is made up of departmental chairs and is co-chaired by the hospital CEO and the dean of the university’s medical school. A member of the hospital’s c-suite observed that the data-based decision-making that the transplant center practices appeals to physicians and administrators alike because both groups are inclined to listen and respond to data. He further noted that “without the rigor of data, you have the loudest person in the room saying ‘this is my experience’ and pushing the center into a direction that may not be strategic or helpful.”
    
    
  • The California Pacific Medical Center transplant department describes itself as data driven and reports that because it operates as an independent unit within the hospital, it has access to detailed data that are specific to transplant center performance. The department chair relies on data for making decisions and has invested resources in management information systems that will provide the data he needs. He tracks inpatient and outpatient outcomes data for the transplant department on a regular basis and uses that data to identify problems and areas where performance can be improved. Because transplantation is a department, he is also able to track financial data at the patient level “to the nickel” and can analyze the data by payer mix and other variables. Key performance data are shared with hospital leadership on a regular basis. They review the data to assess the center’s progress toward its goals and to identify potential areas for improvement.
    
    

  Key Change Concept 1.2: Develop and implement business/strategic plan to secure institutional resources.

Even when hospitals have established organ transplantation as a strategic priority, transplant center administrators and physician leaders will need to work to continually demonstrate the value of transplantation to the hospital in order to secure resources needed on an ongoing basis to operate high-performing transplant programs. In order to realize goals for growing their programs, most transplant centers require staffing and other hospital resources (e.g., management information systems, clinical and office space, dedicated ORs, etc.). In order to secure the investment in those resources from the hospital, the high-performing transplant centers visited for this study have put time and resources into developing business and strategic plans that identify the targets, goals, and resources required to grow their programs. As part of this process, they have also analyzed and communicated to their hospitals’ leadership what the expected financial and other non-monetary benefits will be for the hospital. This often involves conducting a “downstream” analysis of what the revenue impact will be on other departments that provide services to transplant patients and benefit from an increased volume of transplant patients being served at the hospital.

As reflected in the examples provided in this section, one of the critical steps for transplant centers in lobbying for institutional support to grow their programs is to ensure that they have in place passionate and visionary physician and surgeon leaders who share the centers’ goals of growing the programs. In fact, several of the examples in this section describe how the transplant programs’ growth was initiated during the process of recruiting proactive transplant surgeons. More information about how transplant centers have recruited and organized around strong physician and surgeon leaders can be found under Strategy/Driver 2: Dedicated Teams and Action Item 2.1a (Recruit proactive, experienced, and high-performing surgeons and physicians with a passion for, commitment to, and focus on growing transplantation).

Action Items

• 1.2a: Identify targets, goals, and the resources required to grow the transplant program. Several of the transplant centers visited described how they have been successful in terms of securing institutional support for hiring key staff, expanding or launching programs, or making other important investments. In many cases, this involved developing a business plan that outlined the expected return on investment for the hospital.
  
  
  • When the Cleveland Clinic hired a surgeon to chair the liver transplant team, he worked with the current transplant administrator to develop a business plan that set targets for growth of the program over 3 years, as well as resources he needed to reach the goals. Impressed with the ambitious growth goals laid out in the business plan, hospital administration committed the resources requested. To date, the center’s liver team has met or exceeded its goals for growing the program.
    
    
  • Similarly, when the University of Washington Medical Center was recruiting a liver transplant surgeon to direct its liver transplant program, the surgeon laid out for the center what he thought were ambitious, but achievable goals in terms of increasing the number of transplants, as well as the additional resources that would be required to make that happen. As a condition of accepting the employment offer, he negotiated for some of these resources (e.g., a dedicated transplant hepatologist) and then developed a timeline of additional resources that would be required as the program grew.
    
    
  • The California Pacific Medical Center developed a business plan with a return on investment analysis to build the case for launching a lung transplant program in an already competitive market. The business plan described the expected impact of the new program on the transplant center, the hospital, and the network of hospitals to which it belongs, as well as to its competitors. According to the Director of Transplant Services, the business plan was essential to securing additional support for the launch of the new transplant program.
    
    
  • The New York-Presbyterian Hospital transplant center develops business/strategic plans to guide its transplant programs’ growth. The business plans lay out targets and goals for growth, as well as the needed resources. The business plans are informed by interviews conducted with other high-performing centers around the country about effective strategies for growth and strategic management of transplant programs.
    
    
  • When the Children’s Hospital of Philadelphia hired a prominent transplant surgeon to help grow its pediatric transplant program, the surgeon worked with others in the transplant center to develop a business plan to outline the center’s goals, targets, and resource requirements. The business plan reflected the unique needs of children who are transplant patients because as one surgeon indicated, “kids aren’t just little adults.” The hospital approved the business plan and in the following years, the hospital experienced sustained growth. Transplantation is now one of the seven priority service lines that enjoy strong institutional support.
    
    
• 1.2b: Demonstrate the clinical, economic, and non-monetary benefits of transplantation. Transplant centers report that they have been most successful in receiving support for needed resources to hire staff, expand programs, or provide additional services and supports when they can demonstrate to hospital leadership what the clinical and economic benefits of such initiatives would be. In making resource requests, many of the transplant centers visited develop business plans that articulate what the financial and other benefits would be for the transplant center, as well as the hospital. Financially, these centers understand the advantage of demonstrating to hospital leadership not only what the impact of any new expansion or initiative will be on the transplant center, but also what the “downstream” revenue impact will be on other departments that provide services to transplant patients. In seeking support for launching or expanding programs, transplant center leadership may also highlight to hospital leadership what some of the non-financial benefits of transplantation are in terms of prestige. Transplantation tends to be a high-profile service area and can help hospitals raise funds, recruit the best staff, and attract patients. As one staff member at Hahnemann University Hospital pointed out though, transplant center staff never lose sight of what is most important – the patient. She observed that “you can get wrapped up in the economics, but it’s really simple. It’s about saving lives.”
  
  
  • New York-Presbyterian Hospital’s transplant center has been able to lobby effectively for resources as its programs have expanded in recent years. This support from hospital leadership has been facilitated by the center’s ability to demonstrate its profitability (and the downstream revenues generated by chronic care) as well as the non-monetary benefits of transplantation (e.g., prestige, publicity, and staff excitement). These factors were instrumental in the construction of a pediatric transplant outpatient facility. As previous investments in the transplant center show returns, the case for additional resources becomes easier to make.
    
    
  • The kidney transplant program at New York-Presbyterian Hospital took a less prospective approach than the other organ programs. Rather than request needed resources to comfortably grow over time, the program began to cautiously increase the number of transplants performed until it reached what it determined to be maximum capacity and at that point, made the case to the hospital leadership that resources would need to be invested to help the program grow any further. In this case, coming to the hospital administration demonstrating the potential for growth of the kidney transplant program, as well as the monetary and other benefits that had already been realized by the program’s recent growth, was crucial to securing the substantial resources needed to grow the program even further.
    
    
  • At the Hospital of the University of Pennsylvania, there is a hospital-wide commitment to the transplant center and an understanding that even if the margins are not terribly large, innovations should be supported. This progressive and pragmatic approach is evident in several recent initiatives. The implementation of the Organ Transplant Tracking Record (OTTR) carried licensing, training, and maintenance costs; however, because the transplant center was able to demonstrate the value of improved communication, patient tracking, and data review that OTTR would bring, the hospital’s financial leadership supported the venture. Similarly, the creation of the position of procurement coordinator was approved because the transplant center successfully argued that there was a significant benefit in moving the task of preliminarily accepting organs away from the surgeon. The cost of two procurement coordinators was to be offset by the benefit of allowing surgeons to sleep when organ offers came in during the night and by having trained staff deciding whether or not to preliminarily accept offered organs.
    
    
• 1.2c: Develop impact plans to help anticipate and forecast the downstream effects of the addition of new personnel and technologies. Impact planning plays an essential role in expansion and growth of a transplant program as a program must assess the potential effects of any decision. For instance, if a program recruits a surgeon, additional physicians and coordinators may be required to accommodate the resultant increase in volume of transplant surgeries. Such an increase in volume would also require more access to operating rooms, ICU beds, and other hospital resources. For example, New York-Presbyterian Hospital prepares impact plans to assess how changes in the transplant program (e.g., new hires, practices) will affect its performance. Financial and strategic managers work with transplant personnel to prospectively identify the costs and consequences of new hires or new initiatives. During this process of strategic planning, representatives from New York-Presbyterian Hospital contact other regional hospitals to parameterize the effects of any new policy, practice, or hire. Previous business plans are also reviewed to assess whether or not the transplant program has met its previous goals. Because the transplant center has been clinically and financially successful, it is in a better position to appeal to hospital leadership for resources.
  
  
  

  Key Change Concept 1.3: Actively educate internally about goals, expected outcomes and accountabilities.

For transplant centers, educating hospital staff and leadership about organ transplantation can be important to securing institutional support for resources needed to operate successful and growing transplant programs. Among various areas of health care services, organ transplantation is unique in terms of the resources required to run a high-performing program and the accountabilities of the program to stakeholders outside the hospital.

More so than most other areas of health care services, organ transplantation is highly regulated by governmental and quasi-governmental agencies. As such, transplant centers have substantial data collection and reporting requirements to entities outside the hospital over and above the performance data they collect and report internally. To comply with the data reporting requirements, transplant centers typically make significant investments in management information systems and staff capacity to maintain and operate those systems. As a result, in comparison with other lines of service within a hospital, transplant centers require more resources for staffing and information technology.

Likewise, transplant centers have unique staffing needs in terms of nurse coordinators and allied health professionals. Effective transplant centers provide care and support to patients across the continuum of transplantation from the point of referral to a lifetime of post-transplant care. A transplant center’s roster of patients grows every year as newly transplanted patients join the list of post-transplant patients and are assigned a nurse coordinator. As a result, even when the numbers of transplants that a center performs remains stable over a period of years, the center will periodically need to add post-transplant coordinators and related staff (e.g., social workers, lab technicians) to manage the ever-growing caseload of post-transplant patients.

Transplant center physicians and staff report that they have encountered internal barriers to securing support for needed resources when hospital administrators or department chairs are unaware of the unique needs of transplant programs. Therefore, internal education about what a center’s goals are for growing its organ transplant programs and the outcomes it needs to achieve can help reduce these internal barriers and build support for making needed investments in the programs.

Action Items

• 1.3a: Educate hospital executives, department chairs and other institutional leaders (e.g., governing board) about how transplantation is a unique area of service that requires significant investments in nurse coordinators, information technology and other resources. Several of the transplant centers visited described some of the internal education efforts they have undertaken to increase awareness about the requirements and resource needs of a high-performing transplant program. In some cases, these education efforts were undertaken to build support for a new program or to grow an existing program and in other cases, these were described as ongoing educational efforts.
  
  
  • The chair of the department of transplantation at the California Pacific Medical Center, which is on the verge of launching a lung transplant program, reported the significant amount of internal education and marketing that is required to garner support for a major initiative such as launching a new program. He personally dedicated time over a period of months to educating the hospital’s governing board and other leaders and administrators within the hospital about the center’s vision for a lung transplant program, the need it will fill, and the resources it will require.
    
    
  • When the leadership of the Cleveland Clinic’s transplant center identified an opportunity to grow its liver transplant program, their first step was to commission an independent report for the hospital’s governing board to help them understand the need and the opportunity. Based on the report, the governing board approved the hires of two Nationally prominent liver transplant surgeons, who have contributed to substantial growth of the center’s liver transplant program since their arrival.
    
    
  • The University of Washington Medical Center transplant center holds general education sessions open to all hospital staff about organ transplantation. In addition to providing a basic overview of transplant services, these sessions serve to educate hospital staff about the unique aspects of organ transplantation and are intended to create a greater awareness internally about what it takes to run a high-performing transplant program.
    
    

  Key Change Concept 1.4: Commit to providing a comprehensive, multi-disciplinary approach to the full continuum of transplant care.

One of the themes identified across the site visits is that in order for hospitals to operate high-performing organ transplant programs, they must commit to making the institutional investments necessary to ensure that patients are receiving the highest quality and most appropriate care and that they receive the supports they will need across the continuum of transplant care. This commitment should be reflected in the business and strategic plans for the transplant programs and in the resources allocated to the programs. As discussed under the previous key change concept, transplant program leadership often have to do a substantial amount of education internally to help hospital leadership and the leadership of other departments understand why transplant programs have unique resource needs.

In particular, the centers visited identified three key components of transplant care in which any hospital offering transplant services should invest. The programs should provide care and support to patients across the continuum of transplant services from pre- to post-transplant care. They should provide transplant services as part of a broader spectrum of end-stage organ disease care to ensure that patients have access to all the potential treatment modalities that might be appropriate for them. Lastly, transplant programs should integrate and share expertise with each other because many transplant patients develop problems with multiple organ systems.

Action Items

• 1.4a: Provide care across the continuum of transplantation. All of the transplant centers visited are committed to providing the highest quality of care across the continuum of transplantation from referral to lifelong post-transplant care. In the case of a successful transplant, this can mean a relationship between the center and the patients that spans several decades. The level of commitment that successful transplant centers must have to their patients over the course of their lives is unique among health care services. The lifelong aspect of care also means that centers must be prepared for a patient list that grows every year even if the number of transplant surgeries performed remains stable because all the patients transplanted in a year join the rosters of the centers’ post-transplant patients.
  
  
  • The Mayo Clinic’s³⁴ liver transplant program is committed to providing patient-centered care to transplant patients at every stage of the process. Like many other transplant centers, the center assigns pre-transplant clinical nurse coordinators to patients at the time they are placed on the waiting list. The clinical nurse coordinators, along with a team of physicians, social workers, financial coordinators, and others, help the patients manage their health up until the point of the transplant procedure. Inpatient coordinators manage the patients during their transplant surgery and recovery immediately after the transplant procedure. At discharge, patients are assigned to post-transplant coordinators who follow them for life. The post-transplant coordinators check-in with patients on a regular basis, review lab and test results, and are available to answer questions. Despite the fact that a large percentage of Mayo’s transplant patients are from out-of-state and several are international, the post-transplant coordinators report that it is very rare for them to lose contact with any of their patients.
    
    
  • Likewise, at Stanford, the heart and kidney transplant programs are committed to providing the staff and institutional resources required to provide care and support to patients from their first point of entry through a lifetime of post-transplant care follow-up. The center has invested in the staff capacity to ensure that there are a sufficient number of post-transplant coordinators available to check-in with all post-transplant patients on a regular basis and to make a nurse coordinator available to them at all times to answer questions about their health and their treatment plans. Having this level of staff capacity is not an insignificant investment, but the programs view it as part of their mission to support patients across the continuum of transplant care and have secured the resources from the institution to make that possible.
    
    
• 1.4b: Offer transplant services as part of end-stage disease care. Many of the physicians and staff at the centers visited emphasized that if they are going to offer transplant services, hospitals must commit to providing them as part of a broader spectrum of end-stage disease care. Organ transplantation is one of several treatment modalities for end-stage organ disease and in many cases, it is not the best option. Centers that offer transplant services as part of a continuum of end-stage disease care demonstrate their commitment to providing end-stage organ disease patients with the most appropriate form of treatment for them. As articulated by several of the providers interviewed, the hospitals should be focused on meeting these patients’ needs, whether transplantation is the most appropriate form of treatment, and not on a single-minded goal of growing a transplant program. In fact, hospitals may find that offering the full spectrum of end-stage organ disease services boosts their transplant volumes because even though some patients referred for transplantation may be steered toward another treatment modality, the hospital may receive a higher volume of referrals from payers and community providers who trust that patients will receive the most appropriate form of treatment.
  
  
  • At the University of Washington Medical Center, the transplant programs for kidney, liver, lung, and pancreas are part of organ-specific Care Lines that encompass all end-stage disease services. For example, the lung transplant program is part of a care line for end-stage lung disease services. Lung transplant surgeons and physicians are also involved in providing other end-stage lung disease services, including reduction therapy, which can help sustain them until they can be transplanted. According to one of the lung transplant surgeons, offering lung transplant services as part of end-stage lung disease care provides patients with access to a broader range of services and allows them to make more informed decisions about transplantation because they have been educated about the other treatment modalities as well. He also observed that this arrangement results in far fewer instances of patients being turned away because they are evaluated not only for transplantation, but also for other treatment modalities. This is obviously preferable from the patient perspective, and the center’s staff also take pride and satisfaction in knowing that they will not just turn patients away if transplantation is not an option for them.
    
    
  • At the Cleveland Clinic, transplant services are integrated with a broader spectrum of end-stage disease care services. Patients who are referred for transplantation are evaluated not only for transplantation, but also for other alternative forms of treatment that may be more appropriate. Likewise, patients referred for other end-stage disease care are also evaluated to determine if transplantation would be an appropriate option. According to physicians and staff at the center, this approach to transplant care is consistent to provide patients with the best possible care. They believe that it also may make the Cleveland Clinic a more appealing place for payers and community providers to which to refer patients because they know that patients will be steered toward the treatment modality that is most appropriate for them. In fact, they point to the Cleveland Clinic’s heart program, which has become a destination for end-stage heart services Nationally. Though some patients referred to the program for heart transplantation may ultimately receive another treatment modality, the center believes that being a destination for end-stage heart disease care has resulted in a net increase in the number of heart transplants performed.
    
    
  • At the Hospital of the University of Pennsylvania (HUP), the heart and lung transplant programs are part of the full spectrum of care for end-stage disease. For example, the heart transplant program is part of the heart failure program, where cardiac surgeons and cardiologists provide a range of services and treatments, including electrophysiology and ventricular assist device (VAD) implant surgery as a bridge to transplantation. According to the surgeons and physicians, the breadth of heart failure services attracts patients to HUP, allowing them the opportunity to become educated about transplantation, while having access to other forms of treatment options. In addition, the heart failure program receives patient referrals from other hospitals that do not offer end-stage disease care and from payers who refer their patients to HUP knowing that they will have access to a broad range of end-stage care. Because many patients treated for end-stage heart failure eventually go on to receive a transplant, growing the services offered by the heart failure program has a direct impact on increasing the number of heart transplants performed. Currently, approximately 60 percent of referrals for heart transplants at HUP are composed of patients who were initially treated by the heart failure program.
    
    
• 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). At the Hospital of the University of Pennsylvania, patients receive care beyond the transplant continuum and end-stage disease management. Care is also provided across specialties. This cross-specialty care stems from an institutional culture and structure that encourages surgeons and physicians across departments to work together, recognizing that transplant patients’ needs are not limited to the transplanted organ. For example, liver transplant patients that develop kidney problems post-transplant are cared for by one of the center’s nephrologists.
  
  
  

  Key Change Concept 1.5: Organize transplant services into a service line.

Some of the transplant centers visited have made a strategic decision to organize transplant services into a service line with designated budget and decision-making authority. In the traditional hospital or academic medical center setting, decision-making authority typically rests with functional departments, such as medicine or nursing. In these environments, transplant centers typically do not have independent budget and decision-making authority; rather, they must coordinate with medical, nursing, and other departments on key decisions, such as establishing goals, hiring staff, and allocating resources.

One of the challenges for transplant centers in these types of environments that are seeking to grow their programs is that their goals and the goals of the other departments may not be in alignment, which puts hospital leadership in the position of resolving competing priorities in determining allocation of resources. These arrangements also do not provide for a direct line of accountability for transplant center staff because they report to their respective functional departments (e.g., medicine, surgery) rather than to the transplant center. A frequent complaint among transplant centers operating in these environments is that the decision-making process is inefficient and requires too many sign-offs, which makes it difficult for the centers to rapidly react and adapt to changes in their market environments. For the transplant centers that have been able to break down the traditional silos and streamline transplant services into a service line, the benefits have been an improved and more efficient decision-making process and greater accountability of staff toward achieving transplant center goals.

Action Items

• 1.5a: Integrate all transplant services into a single service line with designated budget and decision-making authority. Only a handful of the centers visited have been able to fully integrate services into a service line with designated budget and decision-making authority. A few others have made strides toward adopting a service line approach, but still lack one or two functions of the service line (e.g., hiring authority). It was noted by many of those interviewed that service lines are particularly difficult to implement in academic medical centers where the silo structure is firmly rooted.
  
  
  • The University of Washington Medical Center, which is an academic medical center, has organized its six highest priority service areas, including organ transplantation, into service lines. The transplant service line, which is currently the second largest of the six service lines, includes all services related to kidney, liver, lung, and pancreas transplants and encompasses services across the continuum of care. As a service line, all transplant services across the continuum of care are integrated into a single administrative and financial unit. The decision to integrate all transplant services into a service line was made to enhance the quality of transplant care and to facilitate growth of the transplant programs, which the hospital considered to be a strategic priority. Hospital leadership report that one of the keys to their success was conducting a series of one-on-one discussions with all clinical and non-clinical staff involved in transplantation to understand their perspectives on what was and was not working well, what challenges would need to be addressed in developing a service line, and to flesh out what their scope of authority would be under the new service line. The interviews helped the hospital gain buy-in for the service line because a forum had been provided for staff to provide input.
    
    
  • The California Pacific Medical Center, which is a private, not-for-profit tertiary hospital, also established transplant services as a service line. The center has a department of transplantation, which, according to the center’s leadership, effectively acts as an independent business unit within the hospital with independent budget and decision-making authority. As with other centers that have adopted a service line approach, the leadership of the transplant service line observed that this structure bypasses layers of committee decision-making that they have encountered at other centers and allows the center to be more nimble and responsive to opportunities.
    
    
  • The Mayo Clinic, which is a private, non-profit medical practice, established a service line approach for its transplant center. In 1999, the Mayo Clinic established a Department of Transplantation for all kidney, liver, lung, heart, pancreas, and bone marrow transplant services. Before then, transplant center staff belonged to different administrative departments. Although the department chair does not have independent hiring authority, it operates virtually like a service line. The department has separate divisions for transplant medicine and transplant surgery, which together encompass the continuum of transplant services. According to the department chair, integrating services into a department has significantly reduced administrative red tape and has facilitated organizing care around the needs of the patients.
    
    
• 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. A critical component of adopting a transplant center service line is establishing a governance and oversight structure that will enhance the center’s ability to achieve its goals, both in terms of quality of care and program growth. For example, the University of Washington Medical Center transplant center established a Service Line Operating Committee, which is made up of surgical, medical, and nursing leaders from the various transplant programs. The committee meets regularly to address all operating issues for the transplant service line, including setting goals, establishing strategic directions, prioritizing and allocating resources, reviewing quality and other performance data, and addressing problems as they arise. The Operating Committee provides an open forum for discussion among transplant physicians and surgeons, which hospital leadership reports has reduced historical tensions between the two groups. The Operating Committee reports to an Oversight Committee that is composed of the chairs of the departments of surgery, medicine, anesthesia, and other departments and is co-chaired by the CEO of the hospital and the dean of the medical school. The Oversight Committee meets on a monthly basis to review and make decisions about issues presented to it by the Operating Committee. According to the hospital’s COO, this collaborative approach to making decisions and setting priorities has made it easier for hospital leadership to oversee transplant services because physicians and surgeons are negotiating and coming to consensus amongst themselves and presenting him with unified requests and recommendations. Before the implementation of the service line, the COO was frequently in the position of sorting through the multiple perspectives and competing priorities.
  
  
• 1.5c: Establish direct line of report for transplant center staff to hospital leadership (e.g., COO). Streamlining the reporting structure for the transplant center and providing direct access to senior hospital leadership is a way that hospitals can facilitate the center’s ability to respond to and resolve issues quickly and efficiently. The more flexible and responsive that centers can be to changes in their environment, the better positioned they are to grow their programs. According to the University of Washington Medical Center (UWMC) transplant center’s administrator, another critical component of the successful implementation of a service line at UWMC has been establishing a direct line of report from the transplant administrator to the hospital’s chief operating officer (COO). According to the administrator, having direct access to the COO, who is knowledgeable about transplantation, is critical to her being able to address and resolve issues quickly and has facilitated the program’s growth over the past several years. This sentiment was echoed by one of the lung transplant surgeons who observed that the center’s direct line of reporting to the hospital’s administration has enabled that program’s growth over the past few years. In his view, because the lung transplant program reports to the COO rather than to the chief of cardiothoracic surgery, it has both the autonomy and the accountability to succeed. In his own words, the center is not “bound by bureaucracy. The immediacy of vertical reporting makes you accountable…if that work were diluted through another program, our outcomes would not be what they are. Independence lends itself to ownership of the program and speaks to our growth.”

³³Unless otherwise noted, “New York-Presbyterian Hospital” refers to both Columbia University Medical Center and Weill Cornell Medical Center.
³⁴ Unless otherwise noted, “Mayo” refers to Mayo Clinic Rochester.