Transplant QAPI Team

•Allies with PI specialist to move forward PI initiatives and drive QPS goals within the transplant program

• Ensures compliance with all regulations on a program and divisional level

• Oversees PI projects to organ programs

• Bridges the gap between NYP and the Transplant program

• Facilitates the Transplant Executive Quality Council

• RNs• Responsible for completion of

all UNOS forms• Partner with Transplant Team

to ensure timely and accurate data

• Conducts compliance chart audits

• Participate in monthly transplant meetings

Quality Management

Specialists

Performance Improvement

Specialist

Provider Quality Champions

Compliance Manager

Director of Operations

QAPI Structure: Sharing Information

NYPH Board of Trustees

NYPH Board of Trustees Quality and Performance Improvement Committee

Quality and Performance Improvement Committee of the Medical Board

Transplant Executive QAPI Committee

Organ Specific QAPI Programs

•Summary of Annual Report to BOT distributed to Transplant Executive Quality Council

•Summary of Transplant Executive Quality Council to organ specific QAPI programs

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Transplant Quality Meeting Structure

Organ Specific QAPI Program

KEEPSAFE/ QA Review

Subcommittee

Transplant Executive

Quality Council

QAPI Meeting Structure (cont)

Organ Program QAPI• Chaired by Medical and Surgical

Director• Facilitated by Physician Quality

Champion• Monthly meetings• Multidisciplinary Attendance• Review of post-transplant

discharges• Quarterly trend Review• Respond to Transplant Executive

Quality Council Directives

KEEPSAFE/QA Review Subcommittee• Quarterly review of all reported

events by category• Includes “reportable” events and

self-reported events• Reports to the Transplant Executive

Quality Council

Transplant Executive Quality Council• Chaired by Chief of Transplant• Attended by transplant program

leadership• Multidisciplinary attendance• Oversight over all organ specific

transplant quality programs• Quarterly trend reviews• Transplant Service Improvement

Projects

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All-Program MetricsPhase Metric Type Metric

Pre-Transplant

Outcome Waitlist mortality

Process/Outcome Waitlist removals for medical condition

Process Referral volume

Process Evaluation volume

Process/Outcome Time from listing to transplant

Transplant Admission

Process Transplant volume

Outcome Hand Hygiene

Process Length of Stay

Outcome Central Line Associated Blood Stream Infection

Process Patient Satisfaction

Post-Transplant

Process/Outcome 30-Day Readmission

Outcome 30-Day Mortality

Outcome One-Year Mortality

Outcome Three-Year Mortality

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Organ Phase Metric Type Metric

Kidney and Pancreas Transplant

Pre-Transplant Outcome Time on the Waitlist (Status 1 and Status 7)

Transplant Admission Process/Outcome Timeliness of Stent Removal

Post-TransplantOutcome Biopsy Confirmed Rejection within six-months post-transplant

Process/Outcome CDC High Risk Monitoring

Adult Liver Transplant

Pre-TransplantOutcome Disease Specific Waitlist Mortality

Outcome Disease Specific Transplant Rate

Transplant Admission Outcome Post-Paracentesis Complications

Post-Transplant Process Development of a complications database

Lung Transplant

Pre-Transplant Process Time from referral to first appointment

Transplant Admission

Outcome Unplanned Return to the OR

Outcome Time on Mechanical Ventilation

Outcome Grade 3 PGD at 72 Hours

Outcome Post-Transplant Airway complications

Heart Transplant

Pre-TransplantProcess/Outcome Adherence to selection criteria

Process/Outcome Review of donor acceptance/selection

Transplant Admission

Outcome Unplanned Returns to the OR

Outcome Surgical Site Infection

Outcome Primary Graft dysfunction

Post-Transplant Outcome Rejection/Infection requiring rehospitalization

Program Indicators/Projects

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Program Indicators/ProjectsOrgan Phase

Metric Type Metric

Pediatric Heart

Transplant Admission Process/Outcome ABO-incompatible blood product ordering

Post-TransplantOutcome Inpatient transplant complications monitoring/review

Outcome Outpatient transplant complications monitoring/review

Pediatric LiverTransplant Admission Process/Outcome Bleeding post-transplant (review of outcomes post modification of

heparin protocol)

Post-Transplant Outcome Biliary complications requiring intervention

Living Donor Kidney

Pre-Donation Process/Outcome Adherence with donor selection criteria

Post-Donation Outcome Post-Donation Complications

All-Phases Process/Outcome Living Donor Database Development

Living Donor Liver Donation/Post-Donation

Outcome Bile leaks requiring treatment

Outcome Living donation resulting in an Incisional hernia

Outcome Living donation cases resulting in the need for blood transfusion