CHAPTER 78: The Role of Quality Management for Monitoring and Improving: A Transplant Program

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. Changes often necessitate a cultural change and certainly take time. There are no quick fixes in QM.

Organ transplantation is one of the most highly regulated services within health care. Therefore, QM programs must be robust, with a strong foundation, including:

• A formalized multidisciplinary QA/PI program for donors and receipts

• A formal communication structures

• A consistent peer review process

• Accurate documentation of errors

• Plan to identify risks, mitigate, and improve

(The following graphic illustrates the Plan, Do, Study, Act methodology.)

In order to accomplish this:

• Clinical and operational indicators need to be developed

• Utilization of external information such as UNET reports/analytics, SRTR (Scientific Registry of Transplant Recipients) and CUSUM (cumulative sum) reports

• Adverse event reporting and grievance processes must be established and communicated

• Patient feedback

• Engaged transplant staff, interdisciplinary team

• Accountability has to be explicitly articulated

• Process and outcome variables have to be defined

• Indicators for donor and recipient must be developed, with numerators and denominators

• Once defined, indicator must reflect, selection, prehospitalization, acute and posttransplant process

All adverse events must be reviewed through a credible, robust process (mortality and morbidity case conference on each patient). Prompt review and acting on findings reduces the chance of the adverse events recurring.

• Accountability has to be explicitly articulated

• Process and outcome variables have to be defined

• Indicators for donor and recipient must be developed

• Once defined, indicator must reflect, pre-, acute, and posttransplant process

• Analytics have to be developed

A well-defined dashboard is essential:

• Determine metrics:

  • CMS and OPTN regulatory requirements

  • QAPI focus

  • Corrective action monitoring

  • Department specific data

• Format by transplant phase

  • Pretransplant:

    • # referrals

    • Evaluations-listing days

    • Wait list removal and letter sent within required period

    • 2 ABO prior to listing

    • Living donor: serologies prior to nephrectomy, ILDA documentation

  • Transplant:

    • Graft type

    • DGF

    • Audit results: ABO in the operating room and other vital data form compliance

    • Consent signing

    • LOS

  • Posttransplant:

    • Graft loss within 1 year of transplant

    • Death within 1 year of transplant

    • Rejection rates

    • UNOS-defined adverse events

    • TIEDI form submission

    • Complications

    • Readmission rates

• Infection prevention indicators^*

  • Surgical site infection (SS)

  • Catheter-associated urinary tract infection (CAUTI)

  • Central line–associated bacteremia infection (CLABI)

  • Secondary bacteremia

  • Cytomegalovirus (CMV)

  • Epstein-Barr virus (EBV)

  • Clostridium difficile infection (CDI)

  • Vancomycin-resistant enterococci (VRE)

  • Methicillin-resistant Staphylococcus aureus (MRSA)

  • Carbapenem-resistant Enterobacteriaceae (CRE)

  • Ventilator-associated pneumonia (VAP)

  • COVID-19

As part of the evaluation process, selection criteria for recipients and living donors:

• Department develops specific, written selection criteria for potential recipients and living donors

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