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Seattle Children’s Hospital

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Presentation on theme: "Seattle Children’s Hospital"— Presentation transcript:

1 Seattle Children’s Hospital
Transplant QAPI at Seattle Children’s Hospital Kathy Jo Freeman, RN, MSN Director, Transplant Service Line Seattle Children’s Hospital October 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 Quality QAPI Plan The 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 Methods Continuous Process Improvement Plan Do Check Act Based on the Toyota Production System (TPS)

5 Transplant Quality Committee
Organizational Structure Board of Trustees Quality Improvement Steering Committee Transplant Quality Committee Transplant Team Front Line Staff

6 Transplant Quality Process One outcome and one process measure is defined for each organ in each phase of transplantation (pre, txp & post) A target is set for each metric Data definitions are developed for each metric Data is collected and reported Results are tracked and trended over time Actions are defined and taken Data is re-measured

7 Pediatric intestinal and/or multivisceral
Metrics Grid Pediatric Kidney Transplant Activities/ Process Metrics/ Benchmarks Patient Outcomes Metrics/Benchmarks Pre-transplant SW assessment with psychosocial risks conversation evaluation Compliance with CMS Tag X164 / 95% Immunization selection & 90 days > selection Selection 66% >90 days Transplant ABO verification in OR 100% Length of Stay 10% reduction based on FY13 data Post-transplant Stent Removal Division protocol 100% Early rejection (6 mo) 10-30% Pediatric Liver Nutrition assessment documented prior to listing Compliance with CMS Tag X094 / 95% Active Wait Time, listing to transplant 10% reduction based on FY12-FY13 data Unplanned returns to OR (7 days) <20% Viral surveillance Division protocol 90% 15-40% Pediatric Heart Pharmacy assessment documented prior to listing Compliance with CMS Tag X082 / 95% WL removal too sick for transplant 10% Unplanned returns to OR / Cardiac Cath Intervention (30 days) Pediatric intestinal and/or multivisceral SRTR update (bi-yearly) letters saved to patient EMR Compliance with CMS Tag X155 / 95% 0-40%

8 Data Definition Worksheet

9 Process Improvement

10 Overall Learnings Leadership, ownership, and accountability are key “if everyone is responsible, no one is responsible” Define metrics that are meaningful, actionable and measurable Do not try to measure everything– be intentional

11 Overall Successes and Challenges
Data collection has become part of our routine Regular reports on QAPI have increased team involvement Program is robust and a key focus of our work Challenges Metrics are difficult to define Data collection is cumbersome and mostly manual

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