Quality Assessment

1
Quality Assessment Performance
Improvement(QAPI)

• Synergy of 3 Estates

2
Synergy

• When a teams natural diversity
• combines
• unique perspectives and
• solutions
• not imaginable by any one person
• emerges.
• Human Synergy

3
Objectives

• At the end of this session the attendee will be
• 1. Be able to identify with the importance of
  QAPI program
• 2. Be able to appreciate how synergy can
  increase joint performance between the 3 estates
• 3. Knowledgeable in the use of objective
  measurements to evaluate
• performance
• 5. Able to better document/track progress
  towards continuous quality
• improvement

4
National Organ Donation Infrastructure
Donor Families
Potential Deceased Donor Population
900 Donor Hospitals
58 OPOs
11 OPTN Regional Programs
58 Donor Service Areas
Joint Commission
OPTN
Potential Recipient Populations
UNOS
212 Organ Transplant Centers
Insurance
Donation Waitlist
UNOS Regional Administrators
Organ Recipients
Survival Rates
CMS
5
3 Estates System Serving 2 Populations
Donor Family
Organ Recipient
BOLD GOALS
National System
221Transplant Centers
900 Donor Hospitals
Science Of Change
58 OPOs
6
Accountability By ALL DSA
Donor Family
Organ Recipient
BOLD GOALS
58 Donor Service Areas
Donor Hospitals
Transplant Centers
Science Of Change
OPOs
7
Accountability By LOCAL DSA
Donor Family
Organ Recipient
BOLD GOALS
Donor Service Area
13Transplant Centers
220Donor Hospitals
Science Of Change
OneLegacy
8
DSA Three Estate Joint Accountability
Conversion Rates
DMG OTPD
Wait List Capacity
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Accountability of 3 Estates and CMS
SCOPE Of QAPI Programs Donor Hospitals 482.21
Condition of participation Quality Assurance
and Performance Improvement. The hospital must
develop, implement, and maintain an effective,
ongoing, hospital-wide, data-driven quality
assessment and performance improvement
program. The hospitals governing body must
ensure that the program reflects the complexity
of the hospitals organization and services
involves all hospital departments and services
(including those services furnished under
contract or arrangement) and focuses on
indicators related to improved health outcomes
and the prevention and reduction of medical
errors. Organ Procurement Centers 486.348
Condition of participation Quality Assessment
and Performance Improvement (QAPI) The OPO must
develop, implement, and maintain a comprehensive,
data-driven QAPI program designed to monitor and
evaluate performance of all donation services,
including services provided under contract. The
OPOs QAPI program must include objective
measures to evaluate and demonstrate improved
performance with regard to OPO activities, such
as hospital development, designated requestor
training, donor management, timeliness of on-site
response to hospital referrals, consent
practices, organ recovery and placement, and
organ packaging and transport. The OPO must take
actions that result in performance improvements
and track performance to ensure that improvements
are sustained. Transplant Centers 482.96
Condition of participation Quality Assessment
and Performance Improvement (QAPI). Transplant
centers must develop, implement, and maintain a
written, comprehensive, data-driven QAPI program
designed to monitor and evaluate performance of
all transplantation services, including services
provided under contract or arrangement. The
transplant centers QAPI program must use
objective measures to evaluate the centers
performance with regard to transplantation
activities and outcomes. Outcome measures may
include, but are not limited to, patient and
donor selection criteria, accuracy of the waiting
list in accordance with the OPTN waiting list
requirements, accuracy of donor and recipient
matching, patient and donor management,
techniques for organ recovery, consent practices,
patient education, patient satisfaction, and
patient rights. The transplant center must take
actions that result in performance improvements
and track performance to ensure that improvements
are sustained.
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Accountability of 3 Estates and CMS
Scope of QAPI Program
DONOR HOSPITALS Compassionate End of Life Care
For Potential Donor Families PATIENT SAFETY
ONELEGACY (OPO) Stewardship Of Donor Family
Legacy Recipient IMPROVED OUTCOMES
TRANSPLANT CENTERS Capacity to Meet Demand of
patients waiting for Organ Tx IMPROVED OUTCOMES
Communicate Critical Test Results ABO
Verification Time- Out
Communicate Critical Test Results ABO
Verification Time- Out
Communicate Critical Test Results ABO
Verification Time- Out
11
Accountability of 3 Estates and CMS

• Donor Hospitals
• 482.21 Condition of participation Quality
  Assurance and Performance Improvement
• The hospital must develop, implement, and
  maintain an effective, ongoing, hospital-wide,
  data-driven quality assessment and performance
  improvement program.
• The hospitals governing body must ensure that
  the program reflects the complexity of the
  hospitals organization and services involves
  all hospital departments and services (including
  those services furnished under contract or
  arrangement) and focuses on indicators related
  to improved health outcomes and the prevention
  and reduction of medical errors.

• Organ Procurement Centers
• 486.348 Condition of participation Quality
  Assessment and Performance Improvement (QAPI)
• The OPO must develop, implement, and maintain a
  comprehensive, data-driven QAPI program designed
  to monitor and evaluate performance of all
  donation services, including services provided
  under contract.
• The OPOs QAPI program must include objective
  measures to evaluate and demonstrate improved
  performance with regard to OPO activities, such
  as hospital development, designated requestor
  training, donor management, timeliness of on-site
  response to hospital referrals, consent
  practices, organ recovery and placement, and
  organ packaging and transport. The OPO must take
  actions that result in performance improvements
  and track performance to ensure that improvements
  are sustained.

12
Accountability of 3 Estates and CMS

• Donor Hospitals
• 482.21 Condition of participation Quality
  Assurance and Performance Improvement
• The hospital must develop, implement, and
  maintain an effective, ongoing, hospital-wide,
  data-driven quality assessment and performance
  improvement program.
• The hospitals governing body must ensure that
  the program reflects the complexity of the
  hospitals organization and services involves
  all hospital departments and services (including
  those services furnished under contract or
  arrangement) and focuses on indicators related
  to improved health outcomes and the prevention
  and reduction of medical errors.

• Organ Procurement Centers
• 486.348 Condition of participation Quality
  Assessment and Performance Improvement (QAPI)
• The OPO must develop, implement, and maintain a
  comprehensive, data-driven QAPI program designed
  to monitor and evaluate performance of all
  donation services, including services provided
  under contract.
• The OPOs QAPI program must include objective
  measures to evaluate and demonstrate improved
  performance with regard to OPO activities, such
  as hospital development, designated requestor
  training, donor management, timeliness of on-site
  response to hospital referrals, consent
  practices, organ recovery and placement, and
  organ packaging and transport. The OPO must take
  actions that result in performance improvements
  and track performance to ensure that improvements
  are sustained.

13
Accountability of 3 Estates and CMS
Scope of QAPI Program
DONOR HOSPITALS Compassionate End of Life Care
For Potential Donor Family PATIENT SAFETY

• Communicate Critical Test Results
• Contact OneLegacy
• 1 800 338-6112
• ABO Verification
• 2 staff verify information prior to
• Blood transfusion
• Time Out
• Medication Administration
• OR procedures

Communicate Critical Test Results ABO
Verification Time- Out
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Accountability of 3 Estates and CMS
Scope of QAPI Program

• Communicate Critical Test Results
• Contact Transplant Centers Tissue Processors
• ABO Verification
• Enter in Donor.Net
• Verification of Information in OR
• Time Out
• Packaging of Organs
• DCD Roles Responsibilities

ONELEGACY (OPO) Stewardship Of Donor Familys
Legacy Recipient IMPROVED OUTCOMES
Communicate Critical Test Results ABO
Verification Time- Out
15
Accountability of 3 Estates and CMS

• Transplant Centers
• 482.96 Condition of participation Quality
  Assessment and Performance Improvement (QAPI).
• Transplant centers must develop, implement, and
  maintain a written, comprehensive, data-driven
  QAPI program designed to monitor and evaluate
  performance of all transplantation services,
  including services provided under contract or
  arrangement.
• The transplant centers QAPI program must use
  objective measures to evaluate the centers
  performance with regard to transplantation
  activities and outcomes. Outcome measures may
  include, but are not limited to, patient and
  donor selection criteria, accuracy of the waiting
  list in accordance with the OPTN waiting list
  requirements, accuracy of donor and recipient
  matching, patient and donor management,
  techniques for organ recovery, consent practices,
  patient education, patient satisfaction, and
  patient rights. The transplant center must take
  actions that result in performance improvements
  and track performance to ensure that improvements
  are sustained.

• Organ Procurement Centers
• 486.348 Condition of participation Quality
  Assessment and Performance Improvement (QAPI)
• The OPO must develop, implement, and maintain a
  comprehensive, data-driven QAPI program designed
  to monitor and evaluate performance of all
  donation services, including services provided
  under contract.
• The OPOs QAPI program must include objective
  measures to evaluate and demonstrate improved
  performance with regard to OPO activities, such
  as hospital development, designated requestor
  training, donor management, timeliness of on-site
  response to hospital referrals, consent
  practices, organ recovery and placement, and
  organ packaging and transport. The OPO must take
  actions that result in performance improvements
  and track performance to ensure that improvements
  are sustained.

16
Accountability of 3 Estates and CMS

• Transplant Centers
• 482.96 Condition of participation Quality
  Assessment and Performance Improvement (QAPI).
• Transplant centers must develop, implement, and
  maintain a written, comprehensive, data-driven
  QAPI program designed to monitor and evaluate
  performance of all transplantation services,
  including services provided under contract or
  arrangement.
• The transplant centers QAPI program must use
  objective measures to evaluate the centers
  performance with regard to transplantation
  activities and outcomes. Outcome measures may
  include, but are not limited to, patient and
  donor selection criteria, accuracy of the waiting
  list in accordance with the OPTN waiting list
  requirements, accuracy of donor and recipient
  matching, patient and donor management,
  techniques for organ recovery, consent practices,
  patient education, patient satisfaction, and
  patient rights. The transplant center must take
  actions that result in performance improvements
  and track performance to ensure that improvements
  are sustained.

• Organ Procurement Centers
• 486.348 Condition of participation Quality
  Assessment and Performance Improvement (QAPI)
• The OPO must develop, implement, and maintain a
  comprehensive, data-driven QAPI program designed
  to monitor and evaluate performance of all
  donation services, including services provided
  under contract.
• The OPOs QAPI program must include objective
  measures to evaluate and demonstrate improved
  performance with regard to OPO activities, such
  as hospital development, designated requestor
  training, donor management, timeliness of on-site
  response to hospital referrals, consent
  practices, organ recovery and placement, and
  organ packaging and transport. The OPO must take
  actions that result in performance improvements
  and track performance to ensure that improvements
  are sustained.

17
Accountability of 3 Estates and CMS
Scope of QAPI Program

• Communicate Critical Test Results
• Contact Transplant Recipients
• Test Recipients
• Conference Call 3 Estates
• ABO Verification
• Enter ABO into UNET (2 Separate tests with 2 RNs)
• Verification of Information in Donor Hospital OR
• Verification of Recipient Donor Blood Type at
  TX Center
• Time Out
• DCD Roles Responsibilities
• Prior to transplant

TRANSPLANT CENTERS Capacity to Meet Demand for
Organ Transplant IMPROVED OUTCOMES
Critical Test Results ABO Verification Time- Out
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Accountability of 3 Estates
Organize the QAPI Programs of 3 Estates as the
integration of, and accountability for, three
processes
ABO Verification Communicate Critical Test
Results Time Out
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Highly Focused Performance Challenges

• DCD Lung Challenge
• 7000 Kidney Challenge
• 10 DCD
• 75 Conversion Rates By Large Donor Hospital, By
  DSA
• 3.75 OTPD By Large Donor Hospital, By DSA
• 0 Deaths on the wait list by Transplant Center
• 20 increase in capacity by Transplant Center
• Pediatric Donation

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• The best way
• to predict the future is
• to CREATE it
• 
  Peter Drucker

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Take Home Messages

• What exciting things did you hear in this
  presentation?
• 1. Insights I gained on how QAPI links the
• 3 estates together__________________.
• 2. Actions I can take to jointly improve
• performance and help improve the DSA
• Gaps_____________________________.

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