Quality Matters: Metrics for Living Donor Program

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1 Quality Matters: Metrics for Living Donor Program Marian O Rourke, RN, BSN, CCTC Associate Director, Quality, Compliance & Outcomes Management Objectives Discuss the core components of a quality management program for living donation Describe key elements of a QAPI Plan Identify at least 5 process indicators and 5 outcome indicators to assess quality in living donation Discuss data collection and data presentation 1

2 What is Quality? Institute of Medicine (IOM) The extent to which health services provided to individuals and patient populations improve desired health outcomes Systems awareness and systems design are important for heath professionals but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your professions, you have to love your God. If you have love, you can then work backward to monitor and improve the system Donabedian,

3 Institute of Medicine Effective The health care system should match care to science, avoiding both overuse of ineffective care and underuse of effective care. Efficient The reduction of waste and, thereby, the reduction of the total cost of care should be never-ending, including, for example, waste of supplies, equipment, space, capital, ideas, and human spirit Equity The system should seek to close racial and ethnic gaps in health status. Institute of Medicine Patient-centeredness Health care should honor the individual patient, respecting the patient s choices, culture, social context, and specific needs. Timeliness Care should continually reduce waiting times and delays for both patients and those who give care. Safe Patients ought to be as safe in health care facilities as they are in their homes 3

4 Quality in Living Donation Mandate to do no harm Patient undergoing general anesthesia and surgery without any medical benefit to self Stakes are much higher in Living Donation Any complication is undesired Minimal acceptable risks Imperative to mitigate risk To donor To recipient To surgeon/health care team To hospital institution Defining Quality Improvement We propose defining it as the combined and unceasing efforts of everyone healthcare professionals, patients and their families, researchers, payers, planners and educators to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development. This definition arises from our conviction that healthcare will not realize its full potential unless change making becomes an intrinsic part of everyone s job, every day, in all parts of the system. What is quality improvement and how can it transform healthcare? Paul B Batalden1, Frank Davidoff2Qual Safe Health Care2007;16:2-3 doi: /qshc

for improvement Addresses gaps in systems or processes Develops or implements an improvement or corrective plan

5 Quality Improvement A comprehensive approach to ensuring high quality care Full spectrum of living donation Objective and proactive approach to improving the quality of care and services provided to patients Data driven Identifies opportunities for improvement Addresses gaps in systems or processes Develops or implements an improvement or corrective plan Continuously monitors effectiveness of interventions Quality Improvement Data Collection Change & Improvement Analysis/ Assessment 5

Quality Assessment Performance Improvement Patient Safety/Adverse Events Quality Management Quality Assurance Relates to monitoring & compliance Reactive - works on problems after they occur Led by

6 Quality Assessment Performance Improvement Patient Safety/Adverse Events Quality Management Quality Assurance Relates to monitoring & compliance Reactive - works on problems after they occur Led by management It GUARANTEES quality Asks if standards were met? Are deficiencies corrected? Performance/Quality Improvement Relates to learning and improvement Proactive works on processes before problems occur Relies on measurement Data-driven decisions Led by staff team effort Continuous Errors seen as opportunities for learning 6

7 Quality Structure Process Outcome CMS CoP Transplant centers must develop. Implement, and maintain a written, comprehensive, data-driven QAPI program designed to monitor and evaluate performance of all transplantation services, including those under contract or arrangement. Contract or arrangement significant for programs participating in paired exchange. 7

8 An effective transplant quality assurance and performance improvement (QAPI) program is ongoing and comprehensive, dealing with the full range of services offered by the transplant program, including patient safety, clinical care, quality of life, and those services provided under contract or arrangement. The program is data driven, reflects the complexity of transplant services, and addresses all systems of care and management practices relevant to transplantation. The program is therefore multi disciplinary and covers all phases of transplant care in a continuous cycle of review and improvement. Transplant QAPI is connected or integrated with the hospital quality program and includes processes to identify high risk, high (or very low) volume, and problem prone areas. Feedback, Data Systems, & Monitoring Governance & Leadership Design & Scope Transplant QAPI Transplant QAPI Systematic Analysis & Action Patient Safety & Adverse Events Performance Improvement 8

Organizational Structure Kidney living donation

Organizational Structure Separate living donor

Determined by Size (number of organ transplant

Quality organizational structure of your hospital

identifiable and reported separately Demonstrates

9 Organizational Structure Kidney living donation Liver living donation Paired exchange program Organizational Structure Separate living donor QAPI committee is not required May be necessary Determined by Size (number of organ transplant programs) Transplant center or institute model Quality organizational structure of your hospital Metrics must be specific to living donors Clearly identifiable and reported separately Demonstrates alignment and reporting through organization to the governing Board 9

QAPI Structure for Living Donation Transplant separate QAPI from Hospital Living donation may be part of kidney or liver QAPI committee Living donation may be part of the transplant center QAPI

10 QAPI Structure for Living Donation Transplant separate QAPI from Hospital Living donation may be part of kidney or liver QAPI committee Living donation may be part of the transplant center QAPI Committee Living donation may be separate QAPI Committee Transplant included in Hospital QAPI Living donation should be specifically identified MTI Quality Structure Jackson Memorial Hospital Quality Council Public Health Trust Board of Trustees Jackson Health System Medical Executive Committee Transplant Quality Council Holtz Children s Hospital Quality Council MTI M&M Conference/Thorough Review of Transplant AE MTI QAPI Committee JHS Risk Management JHS Peer Review Transplant Patient Safety Council Kidney & Pancreas QAPI Living Donor QAPI Intestine QAPI Liver QAPI Thoracic & VAD QAPI Pediatric QAPI 10

11 Communication Vertical up Diagonal Vertical down Horizontal Governance Health System Governing Board Medical Executive Committee Transplant Steering Council Transplant QAPI Committee Living Donor QAPI Committee System Patient Safety Council 11

Quality Plan Comprehensive, overarching, dynamic document that functions as an implementation tool for the program Living donation must be identified as a specific focus/scope of service Include at a

12 Quality Plan Comprehensive, overarching, dynamic document that functions as an implementation tool for the program Living donation must be identified as a specific focus/scope of service Include at a minimum Scope of service Commitment statement Delineation of authority/responsibilities Information flow/communication Integration of all indicator activities and projects Quality assessment/assurance Performance improvement Adverse event/patient safety Sample QAPI Plan Table of Contents Who is the MTI - Mission, Vision, Goals Scope of Service type of services and population (living donors) Statement of purpose Guiding principles Quality Objectives/Goals QAPI Indicators Regulatory Compliance & Process Control Contracted services Governance & Leadership overview of the structure, committee charters and membership Performance Improvement methodology Adverse events Frequency of plan re-view and evaluation 12

QAPI Policy & Procedure Policy and procedure is an abbreviated, less detailed, outline of the quality activities Must include living donation specifically Address Organizational structure of QA Scope

13 QAPI Policy & Procedure Policy and procedure is an abbreviated, less detailed, outline of the quality activities Must include living donation specifically Address Organizational structure of QA Scope of service Information flow Goals Quality Committee Membership Multidisciplinary Physician Surgeon Independent Living Donor Advocate Living Donor Coordinator Social Worker Pharmacist Dietitian Support Staff Ancillary Areas Histocompatibility Lab Nursing Unit Risk Manager Quality staff OR staff Ad Hoc Membership 13

14 Committee Roles & Responsibilities Identify a Chair or Co-Chair Quality and Medical Decide frequency of meetings Monthly to quarterly Minimum # per year Duration of meetings and timing to accommodate majority of schedules Agenda Identify standing agenda items for every mtg, ad hoc items and frequency of such items Sample Agenda Call to order Approval of minutes Quality indicator review dashboard/scorecard Performance Improvement project review Adverse Events/Donor Safety Donor satisfaction/donor experience data Donor complaints Regulatory updates Policy review and approval Data reporting compliance Staff education offerings 14

State language around the protection of quality and patient safety documents.

15 Minutes Template Person responsible for f/u is critical Summary is important but concrete, specific follow-up action items is critical. Timeframe required. State language around the protection of quality and patient safety documents. Quality Indicators Process Pre Donation Structure Outcome Post Donation Donation Event 15

Indicators Process Defines as a series of actions or functions during the delivery of patient/donor care within the program s system that result in an organ

16 Indicators Process Defines as a series of actions or functions during the delivery of patient/donor care within the program s system that result in an organ transplant Outcome Defined as either a measurement or an event that is the result of the transplant process and directly affects the length or quality of a person s life 16

17 Process Psychosocial clearance Informed consent/education Nutrition screening Pregnancy testing (as applicable) Kidney paired donation readiness process A2 typed prior to donation PHS screenings NAT testing prior to donation OPTN data submission Referral to evaluation completion ILDA documentation Indicators Pre Donation Outcome Higher-risk donor intervention Evaluation complications Weight loss when indicated prior to donation Indicators Peri-Donation Process Final donor and recipient clearance prior to start of either surgery ABO verification in the OR Timeliness of start of OR Outcome Conversion to hand assist laparoscopy Operative times Length of Stay Aborted procedure Return to the OR Blood loss/product use 17

18 Indicators Post Donation Process Multidisciplinary team involvement ILDA involvement LD f/u 6 mos, 12 mos, 24 mos Clinical Laboratory Outcome Re-admission in 7 and 30 days DVT/PR within 30 days Infection within 30 days Corneal abrasion Donor death Developed hypertension or worsening hypertension in 90 days post donation < 25% loss of kidney function within 90 days Higher risk donor interventions pharmacist, dietitian Definition Must be specific identifying The statistical measure (mean, median) Population to be measured (denominator and numerator) Must clearly state what is to be measured Developed hypertension or worsening hypertension in 90 days post donation what is hypertension or worsening hypertension? Benchmark Identify reputable benchmarks for measures OPTN, SRTR, peer review journals Avoid internal/historic benchmarks if possible 18

19 LIVING DONOR PROCESS INDICATORS EXPECTED JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER YTD NUMBER OF LIVING DONOR REFERRALS N # OF LD WHO HAD TISSUE TYPING N REFERRAL TO TISSUE TYPING TIME-DAYS MEDIAN <14 No data min RANGE max # OF LD 1ST CLINIC VISIT N MEDIAN <21 No data PRE TISSUE TYPING TO 1ST CLINIC VISIT TIME-DAYS RANGE min max NUMBER OF LD TO SELECTION MEETING N PERI POST MEDIAN < CLINIC VISIT TO SELECTION MEETING min RANGE max N LIVING DONOR ADVOCATE INTRODUCTION COMPLIANT 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% N LIVING DONOR ADVOCATE PRE-DONATION COMPLIANT 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% EXPECTED JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER EXPECTED NUMBER OF DONATIONS N N ABO VERIFICATION IN OR COMPLIANT 100% 100% 80% 100% 100% 100% 100% 88% 92% 100% 92% 100% 100% % N LIVING DONOR TIEDI REGISTRATION FORM COMPLIANT 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% EXPECTED JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER EXPECTED N LIVING DONOR ADVOCATE F/U HOSPITAL COMPLIANT 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 1 N LIVING DONOR FOLLOW-UP FORM COMPLIANT 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Data Management One of the more challenging aspects of quality management Critical component of any quality assurance/performance improvement efforts Indicator choices may be driven by data availability Need to evolve to capturing required data to facilitate robust meaningful quality indicator monitoring Indicators identified in EMR problem list 19

20 Identify source of data If data not already being documented as part of the normal work flow/medical record documentation identify who, how, and when it will be captured Identify who will capture or abstract data from record Manual Electronic How will data be validated? Consider random manual record audit to validate electronic report Data integrity Understand who/where data is originating from if EMR interfaces with transplant data base, complications and diagnosis may be grossly inaccurate 20

February March April May June July August September October November December Pareto: Compares

21 Run Chart % of LD that came for scheduled f/u Percent of Patients with Planned Care Visits 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Target Reminder Calls Implemented Staff vacancy January February March April May June July August September October November December Pareto: Compares causes of a process problem in rank-order or priority identify where to focus improvement efforts 21

22 Pie Chart LDR LDF 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Bar Chart 22

23 Performance Improvement Act Plan Study Do Many methods and tools available Choose same tool and method as your hospital uses Alignment of transplant and hospital quality structures, goals and processes is necessary Develop documentation format for method Easy to use However, supports succession planning Adverse Event/Patient Safety Magnitude and impact of an adverse event in a living donors cannot be underestimated Serious (beyond the OPTN required reporting) adverse events in LD should initiate an RCA Meticulous review of all near misses to avoid adverse event Create a culture of transparency and make it safe to report events Leadership must lead by example Provide feedback to LD team of improvements made based on events reported Maintain report of all non-conformities in living donors 23

Living Donor Experience Living donors have different expectations Healthy, never hospitalized No personal medical gain Pain management high priority Complaints are valuable source of improvement

24 Living Donor Experience Living donors have different expectations Healthy, never hospitalized No personal medical gain Pain management high priority Complaints are valuable source of improvement opportunities Immediate service recovery efforts expected All complaints/grievances should be reported Trend and collate results to identify opportunities for improvement efforts Generic hospital/clinic surveys not specific to LD Benefit of LD specific survey Focused LD survey (topic or process specific related Miscellaneous Items Paired exchange should be addressed in quality plan or quality indicators Demonstrate communication of quality initiatives and results to staff Ensure staff can speak to quality and specifically LD quality initiatives Job descriptions and competencies for all LD team members should include responsibility for quality and performance improvement Identify who is responsible to coordinate and drive quality initiatives for LD program and transplant program Quality management is not a PRN activity! 24

25 Living Donor Experience Living Donor Satisfaction Surveys Living donors have different expectations Healthy, never hospitalized No personal medical gain Pain management high priority Complaints are valuable source of improvement opportunities Immediate service recovery efforts expected All complaints/grievances should be reported Trend and collate results to identify opportunities for improvement efforts Resources The Improvement Guide. Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. Jossey Bass Built To Last. Collins JC, Porras JI. HarperCollins Publishing Hardwiring Excellence. Studer Q. Fire Starter Publishing Lean-Six Sigma for Healthcare: A Senior Leader Guide to Improving Cost and Throughput. Chip Caldwell, Jim Brexler,Tom Gillem A Lean Guide to Transforming Healthcare: How to Implement Lean Principles in Hospitals, Medical Offices, Clinics, and Other Healthcare Organizations Zidel, Thomas G. Lean Six Sigma Demystified. Arthur J, McGraw Hill The Janet A. Brown Healthcare Quality Handbook A professional Resource and Study Guide, 27 th Edition, 2013 Janet A. Brown

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The Multidisciplinary Team. The Kidney Donor Surgical Team Benefits and Challenges. New Initiative: The Center for Living Donation

The Multidisciplinary Team. The Kidney Donor Surgical Team Benefits and Challenges. New Initiative: The Center for Living Donation The Recanati/Miller Transplantation Institute at The Mount Sinai Medical Center Recanati Miller Transplantation Institute: The Center for Living Donation Support for the Donor Through All phases of Donation