Presentation on theme: "Seattle Children’s Hospital"— Presentation transcript:
1 Seattle Children’s Hospital Transplant QAPI atSeattle Children’s HospitalKathy Jo Freeman, RN, MSNDirector, Transplant Service LineSeattle Children’s HospitalOctober 3, 2013
2 “Not everything that can be counted counts, and not everything that counts can be counted.” Sign hanging in Einstein’s office at Princeton
3 Transplant QualityQAPI PlanThe Transplant Quality Assessment and Performance Improvement (QAPI) program oversees the overall quality management of the three phases of solid organ transplantation. Through continuous QAPI efforts, patient processes and outcomes will be measured and improved.
4 Continuous Process Improvement QAPI MethodsContinuous Process ImprovementPlanDoCheckActBased on the Toyota Production System (TPS)
5 Transplant Quality Committee Organizational StructureBoard of TrusteesQuality Improvement Steering CommitteeTransplant Quality CommitteeTransplant TeamFront Line Staff
6 Transplant QualityProcessOne outcome and one process measure is defined for each organ in each phase of transplantation (pre, txp & post)A target is set for each metricData definitions are developed for each metricData is collected and reportedResults are tracked and trended over timeActions are defined and takenData is re-measured
7 Pediatric intestinal and/or multivisceral Metrics GridPediatric KidneyTransplant Activities/ ProcessMetrics/ BenchmarksPatient OutcomesMetrics/BenchmarksPre-transplantSW assessment with psychosocial risks conversation evaluationCompliance with CMS Tag X164 / 95%Immunization selection & 90 days > selectionSelection 66%>90 daysTransplantABO verification in OR100%Length of Stay10% reduction based on FY13 dataPost-transplantStent RemovalDivision protocol 100%Early rejection (6 mo)10-30%Pediatric LiverNutrition assessment documented prior to listingCompliance with CMS Tag X094 / 95%Active Wait Time, listing to transplant10% reduction based on FY12-FY13 dataUnplanned returns to OR (7 days)<20%Viral surveillanceDivision protocol 90%15-40%Pediatric HeartPharmacy assessment documented prior to listingCompliance with CMS Tag X082 / 95%WL removal too sick for transplant10%Unplanned returns to OR / Cardiac Cath Intervention (30 days)Pediatric intestinal and/or multivisceralSRTR update (bi-yearly) letters saved to patient EMRCompliance with CMS Tag X155 / 95%0-40%
10 Overall LearningsLeadership, ownership, and accountability are key“if everyone is responsible, no one is responsible”Define metrics that are meaningful, actionable and measurableDo not try to measure everything– be intentional
11 Overall Successes and Challenges Data collection has become part of our routineRegular reports on QAPI have increased team involvementProgram is robust and a key focus of our workChallengesMetrics are difficult to defineData collection is cumbersome and mostly manual
Your consent to our cookies if you continue to use this website.