Membership & Professional Standards Committee (MPSC) Spring 2014

Recent Public Comment Proposals Proposed Patient Notification of Functional Inactivity Due to Lack of Transplant Activity March 2014 – MPSC review of public comment & responses Post public comment amendment Board Review – June 2014 Implementation Date – September 1, 2014, if approved A proposal to require programs to notify their patients when they are identified for functional inactivity due to lack of transplant activity went out for public comment in Fall 2013. We will be reviewing the public comments and determining the committee response at our March meeting. We will also consider a post-public comment amendment. The amendment includes a revised definition of the term potential candidate in the proposal so it’s consistent with the definition in Appendix M of the bylaws. The amendment would remove the phrase “including those currently in the referral or evaluation process” and would instead rely on the definition of “potential candidate” in the definitions in Appendix M which states: “A potential candidate is defined as an individual who is under evaluation for transplant by the transplant program. If we determine to go forward with the proposal, the Board will review the proposal at the June 2014 Board meeting. Programs identified for functional inactivity after the September 1, 2014 effective date would be required to send notification to candidates and patients under evaluation.

Recent Public Comment Proposals Proposal to Revise the Current Method for Flagging for Transplant Program Post-transplant Performance Reviews March 2014 – MPSC review of public comment & responses Board Review – June 2014 Implementation Date – January 1, 2015, if approved A proposal to revise the current method for flagging for transplant program post-transplant performance reviews went out for public comment in Fall 2013. We will be reviewing the public comments and determining the committee responses at the March meeting. If we decide to go forward with the proposal, the Board will review the proposal at the June 2014 Board meeting. If approved by the Board, the new thresholds and Bayesian methodology will be utilized for the January 2015 reports on patient and graft survival produced by the SRTR for the MPSC. No matter what happens with the current proposal, we will continue to evaluate how we identify programs for review for post-transplant outcomes and will consider the suggestions included in the public comments.

Ongoing Committee Initiatives Review of bylaw requirements/qualifications for primary surgeons and physicians Procurement requirements Defining “foreign equivalency” Defining “working knowledge” and “currency” Revisit the definition of a member transplant hospital Codified vs operational understanding Identifying impacts if kept as is or if revised The MPSC work group charged with reviewing bylaw requirements for primary surgeon and primary physician qualifications has recommended bylaw modifications that will be considered by the MPSC during its March 2014 meeting. These modifications will result in greater consistency across all organs regarding procurement requirements for the primary surgeon.  We’ll provide more detail during the Fall regional meeting if the committee has the proposal ready for public comment. Topics this work group will consider include defining foreign equivalent training and certification, and defining working knowledge and currency. Because healthcare institutional governance relationships are constantly changing, we need to review the definition of a member transplant hospital. A member transplant hospital has traditionally been a single facility performing transplant surgery. Now, requests are being submitted to recognize a single member transplant hospital, which is performing the same type of organ transplant in more than one geographically separated site. There are challenges with allowing this, so the MPSC is exploring if we need to change to what establishes a member transplant hospital and where we need to make the changes.

New Committee Initiatives OPTN Quality Assurance and Process Improvement (QAPI) requirement Committee will review language March 2014 Fall 2014 public comment Over the last couple of meetings, we have been looking at the possibility of including a requirement in the bylaws for members to have a QAPI plan. They would also be required to implement the plan. This plan would not be routinely monitored. The MPSC would only review a member’s QAPI program if they were already reviewing a compliance or performance issue. We will be considering proposed language at our March meeting. The proposed language would include a brief description of the required components. In addition, every effort will be made to make sure that any OPTN requirement is consistent with the CMS requirements. We anticipate a proposal going out for public comment in Fall 2014.

Questions? Carl Berg, MD Committee Chair carl.berg@duke.edu Name Region # Representative email Sally Aungier Committee Liaison sally.aungier@unos.org