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INTRODUCTION

The basis of any quality management (QM) program is to gather valid and accurate information in order to assess processes and improve outcomes. Because health care services, including transplant services, are highly complex and involve many individuals, improving processes and ingrained habits of behavior can be difficult and require conscious effort.

To promote change and to transform the culture of a transplant service to achieve improved outcomes, individual physician subjectivity needs to be superseded by objective norms, variables, evidence-based measures, and statistical analysis of aggregated data.

Collaboration is essential for everyone involved in the program, including clinical and administrative leadership and the members of the transplant team. Effective analysis of errors requires a straightforward acknowledgment of the complexity of the process and the likelihood of errors occurring. Unless an appreciation of complexity is accepted, prevention and improvement efforts will remain superficial.

Improvements often necessitate a cultural change and certainly take time. There are no quick fixes in QM. Generally, a robust QM program involves:

  • A formalized multidisciplinary quality assurance/process improvement (QA/PI) program

  • A formal communication structure

  • A consistent peer review process

  • Accurate documentation of errors

  • Plan for improvement with goals and targets for the measures

In order to accomplish this:

  • Clinical and operational indicators need to be developed

  • Input from the clinical staff and frontline has to be gathered

  • Input from the patients (both donor and recipient) has to be collected

  • A methodology for PI has to be deployed.

Figure 94-1 illustrates the Plan, Do, Study, Act methodology.

FIGURE 94-1

The Plan, Do, Study, Act methodology.

In order to change a culture, it is necessary to move from a physician-centered model of care to a consumer-driven health care model with a team approach. The goals of a liver transplant QA/PI committee should provide a forum for multidisciplinary team review and discussion of clinical quality issues and outcome data. Performance measures should be established for comprehensive evaluation of performance. The team must also ensure that the transplant service is in compliance with state, federal, and other regulatory agencies.

Core members of a liver transplant QA/PI team should be composed of the following:

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Director, Liver Transplant and Hepatobiliary Surgery

MD

Medical Director, Liver Transplant

MD

Liver Attending

MD

Transplant Attending

MD

Liver and Kidney Transplant Fellow

MD

Transplant Fellow

MD

Hepatologist

MD

Liver Transplant Coordinator

RN

Liver Transplant Coordinator

RN

Liver Transplant Coordinator

RN

Hepatobiliary Coordinator

RN

Liver Transplant Coordinator

RN

Transplant QA/PI Coordinator

RN

Liver Social Worker

CSW

Social Worker

CSW

Dietician

RD

Transplant Pharmacist

PharmD

Transplantation is complex and must be examined through the continuum of care for the donor (living/cadaver) and recipient (Fig. 94-2).

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