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Transplant QAPI at Seattle Childrens Hospital Kathy Jo Freeman, RN, MSN Director, Transplant Service Line Seattle Childrens Hospital October 3, 2013.

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Presentation on theme: "Transplant QAPI at Seattle Childrens Hospital Kathy Jo Freeman, RN, MSN Director, Transplant Service Line Seattle Childrens Hospital October 3, 2013."— Presentation transcript:

1 Transplant QAPI at Seattle Childrens Hospital Kathy Jo Freeman, RN, MSN Director, Transplant Service Line Seattle Childrens Hospital October 3, 2013

2 Not everything that can be counted counts, and not everything that counts can be counted. Sign hanging in Einsteins 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 QAPI Methods Plan DoCheck Act Continuous Process Improvement Based on the Toyota Production System (TPS)

5 Organizational Structure Board of Trustees Quality Improvement Steering Committee Transplant Quality CommitteeTransplant TeamFront 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 Metrics Grid Pediatric Kidney Transplant Activities/ ProcessMetrics/ BenchmarksPatient OutcomesMetrics/Benchmarks Pre-transplantSW assessment with psychosocial risks conversation evaluation Compliance with CMS Tag X164 / 95% Immunization selection & 90 days > selection Selection 66% >90 days TransplantABO verification in OR 100%Length of Stay10% reduction based on FY13 data Post-transplantStent RemovalDivision protocol 100%Early rejection (6 mo)10-30% Pediatric Liver Transplant Activities/ ProcessMetrics/ BenchmarksPatient OutcomesMetrics/Benchmarks Pre-transplantNutrition assessment documented prior to listing Compliance with CMS Tag X094 / 95% Active Wait Time, listing to transplant 10% reduction based on FY12-FY13 data TransplantABO verification in OR100%Unplanned returns to OR (7 days)<20% Post-transplantViral surveillanceDivision protocol 90%Early rejection (6 mo)15-40% Pediatric Heart Transplant Activities/ ProcessMetrics/ BenchmarksPatient OutcomesMetrics/Benchmarks Pre-transplantPharmacy assessment documented prior to listing Compliance with CMS Tag X082 / 95% WL removal too sick for transplant10% TransplantABO verification in OR100%Unplanned returns to OR / Cardiac Cath Intervention (30 days) <20% Post-transplantViral surveillanceDivision protocol 90%Early rejection (6 mo)<20% Pediatric intestinal and/or multivisceral Transplant Activities/ ProcessMetrics/ BenchmarksPatient OutcomesMetrics/Benchmarks Pre-transplantSRTR update (bi-yearly) letters saved to patient EMR Compliance with CMS Tag X155 / 95% WL removal too sick for transplant0 TransplantABO verification in OR100%Unplanned returns to OR (7 days)<20% Post-transplantViral surveillanceDivision protocol 90%Early rejection (6 mo)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 Success 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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