Quality assessments for organ transplantation

In 2007, the United States (U.S.) government issued Conditions of Participation for all solid organ transplant programs. One section of this 100-page document was about Quality. Most nurses working in transplantation knew very little about how to measure quality or how to develop scorecards. I began taking postgraduate courses in quality to develop an understanding about what would be needed to meet the new requirements. Soon I was educating my colleagues what I had learned in my classes. In 2013, six colleagues and I developed an educational conference for our colleagues called the Transplant Quality Institute. This is now an annual event. Last year we hosted almost 400 transplant nurses from around the United States (as well as one nurse from Brazil) for a three-day seminar on quality in Denver, Colorado. In addition, members of this group also started a quality list serve for our colleagues to share information. There are close to 500 members on the list serve asking questions and sharing solutions.

What we have learned since 2007 is that quality assessments do make a difference. When we focus on measuring outcomes, we have learned that we create a safer environment for our patients. Interestingly we have also found that we are creating a much safer environment in which we practice as clinicians. Transplantation is a high risk, high cost area of healthcare. Developing performance measures and monitoring their outcomes leads us to many improvements for our patients and for our clinical practice. Every three years surveyors arrive at our transplant programs to evaluate our quality processes and our patient outcomes. The surveyors review patient charts, interview staff nurses, transplant coordinators, and transplant physicians. They review transplant specific policies to determine that our practice reflects processes described in each policy. Surveyors focus on our multidisciplinary documentation to ensure consistent communication.

We are required to develop performance measures for each of the three transplant phases: pre-transplant, perioperative including discharge, and post-operative or the post discharge follow up phase. Examples of pre-transplant performance measures may include the time it takes for us to complete an evaluation of a patient referred for transplantation. Our goal is 3 weeks or less. In the perioperative period, we measure performances such as the need for a patient to return to the operating room in the immediate post-transplant period. We also measure length of stay in the ICU or length of stay during the transplant admission. Preparing patients for discharge is very important and we must develop a protocol or clinical practice guidelines describing how the discharge process is accomplished. Ensuring a comprehensive hand off from inpatient nurses to the outpatient transplant coordinators is a key performance measure for most transplant programs.

A scorecard must be developed for each organ system within a transplant hospital. Thus, if a hospital performs liver, kidney, pancreas, heart, and lung transplants, there will be five different scorecards monitoring each phase of transplant. If a transplant hospital performs living donor surgeries, a quality program with scorecards is developed to assess and evaluate care of living donors. Most transplant programs have hired at least one quality manager and several data coordinators to meet the demands of auditing, monitoring, analyzing, and reporting data outcomes. In addition to monitoring performance measures, transplant programs must have a process to review adverse events such as the death of a patient or a patient’s graft loss within the first year. Based on the findings of a root cause analysis, a corrective action plan is developed and a performance improvement project is designed and implemented to address the root cause(s) identified in the analysis. Surveyors review each adverse event to determine that we have developed an improvement process that is having positive results and is sustainable.

Each week transplant programs submit data to the United Network for Organ Sharing (UNOS). This data is aggregated, analyzed, and reported publicly twice a year by the Scientific Registry for Transplant Recipients (SRTR).¹ Programs must meet expected outcomes for each organ system based on risk adjustments developed by statisticians and researchers at the SRTR.¹ Patients as well as private and public insurers use SRTR reported outcomes to evaluate organ transplantation at each transplant program in the United States. Insurers determine which transplant programs meet their “Centers of Excellence” based on the outcomes reported by the SRTR. If a transplant program is not a Center of Excellence for an insurance company, patients from that company are not referred to that program.¹Thus, it is clear there is a large financial component tied to the quality and outcomes of each transplant program.

Quality assessments are not unlike research. There are several similarities. In each process, we are collecting and analyzing data with a goal of improving healthcare. The methodologies used in research are more complex and provide us with evidence whereas quality projects provide us with ways to create a safer environment for our patience and our clinical practice.² In each process, we want to demonstrate proof of effectiveness and a sustained improvement. Quality projects may demonstrate more proof of effectiveness and best practice whereas research provides us with more evidence to apply to our practice.²Transplantation has improved over the past 10 years with the application of quality and performance improvement projects to our practice. It has been a steep learning curve but our patients and our environments are safer for the application of this knowledge by transplant nurses.

Linda Ohler, MSN, RN, CCTC, FAAN, FAST
Quality and Regulatory Manager
George Washington University Transplant Institute
Washington, DC
[e-mail]

Referências

• ¹
  Program Specific Reports. Scientific Registry for Transplant Recipients www.srtr.org Acessado em 18 de abril de 2017.
  » www.srtr.org
• ²
  Moses J. What’s the difference between research and quality improvement? Institute of Healthcare Improvement Open School www.ihi.org Acessado em 18 de abril de 2017.
  » www.ihi.org

Publication Dates

• Publication in this collection
  Mar-Apr 2017