QA Investigation Results

Pennsylvania Department of Health
ALBERT EINSTEIN MEDICAL CENTER - TRANSPLANT CENTER
Health Inspection Results
ALBERT EINSTEIN MEDICAL CENTER - TRANSPLANT CENTER
Health Inspection Results For:


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Initial Comments:

This report is the result of an unannounced off site Outcome Non-compliance survey that was completed on August 19, 2011, for the Adult Kidney - Only (AKO) and Adult Liver-Only (ALI) programs at Albert Einstein Medical Center Transplant Center. It was determined that the facility was not in compliance with Part 482- Conditions of Participation for Hospital - Subpart E - Requirements for Specialty Hospital - 482.68 Special Requirements for Transplant Centers.




Plan of Correction:




482.68 CONDITION
SPECIAL REQUIREMENTS FOR TRANSPLANT CENTERS

Name - Component - 00 - Transplant Types: AKO, ALI

A transplant center located within a hospital that has a Medicare provider agreement must meet the conditions of participation specified in 482.72 through 482.104 in order to be granted approval from CMS to provide transplant services.
(a) Unless specified otherwise, the conditions of participation at 482.72 through 482.104 apply to heart, heart-lung, intestine, kidney, liver, lung, and pancreas centers.
(b) In addition to meeting the conditions of participation specified in 482.72 through 482.104, a transplant center must also meet the conditions of participation specified in 482.1 through 482.57.





Observations:

Based on review of the July 2011 outcomes calculated by the Scientific Registry of Transplant Recipients (SRTR), the Adult Kidney - Only (AKO) and the Adult Liver- Only (ALI) programs failed to ensure that the facility met the conditions of participation specified in 482.82 Conditions of Participation: Data Submission, Clinical Experience, and Outcome requirements for Re-approval of Transplant Centers by failing by failing to meet the expected one year post transplant graft survival rates for the AKO program and by failing to meet the expected one year post transplant patient survival rates for the ALI program.





Plan of Correction:

CORRECTIVE ACTION PLAN KIDNEY LOWER THAN EXPECETD 1 YEAR GRAFT SURVIVAL

A full assessment of the kidney transplant program including a detailed analysis of each event that led to a graft failure and/or mortality was completed in November 2010. The entire transplant program was evaluated by senior clinical and administrative leaders to look for opportunities for program improvement. Improvements were made at every phase of the transplant program including the following:

1. Quality Assessment


 Improved outcomes by monitoring past and present mortalities and graft losses through transplant specific M&M (May 2010)
 Improved multidisciplinary engagement by increasing the frequency of discussion among physician leaders (May 2010)
 Audited outcomes on a monthly basis with senior leadership and audited monthly dashboard of outcomes of rejection, infection, return to OR, LOS and other complications (July 2010)
 Improved communication between Transplant QAPI and Hospital QAPI by having a hospital QAPI representative at all transplant QAPI leadership meetings (June 2011)
 Incorporated comprehensive QAPI committees and reporting into the functioning of the department: a) Monthly QAPI Leadership Committee meeting b) Quarterly QAPI Council, c) Monthly Transplant M&M meeting d) Weekly surgical M&M meeting , e) Biannual Performance Improvement Council, f) Quarterly QAPI with Anesthesia

Responsible parties are Administrator, Transplant; Transplant QAPI Nurse Manager
2.
Improved patient evaluation/screening process:

 Improved listing meeting process (August 2010)
 Improved discussion re: risks and benefits for individual patients being presented (August 2010)
 Improved social work screening with individual contracts addressing the area of concern and/or noncompliance (May 2011)
 Pre transplant pharmacist assessment now available (June 2011)
 Required record review before evaluation for all patients who present with high risk factors (June 2011)
 Improved cardiology engagement through implementation of a cardiology risk stratification list when patients are e evaluated for a kidney transplant (July 2011)
 Implemented a social work stratification list to identify absolute and relative contraindications to transplant (August 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program; Transplant Lead Social Worker

3. Improved Waitlist Management

 Increased frequency of updating each wait list candidate (May 2010)
 All wait listed patients are seen for followup annually (May 2010)
 Hired a lead kidney transplant manager to oversee the management of the waitlist (May 2010)
 Implemented a bimonthly multidisciplinary review of the patients with the most time on the list or other factors that would make a candidate likely to be called in for transplant (June 2011)
 Quarterly review of patients 70 years of age and older (June 2011)

Responsible parties are Administrator, Transplant Program; Manager and Lead Kidney Coordinator

4. Improved Patient Compliance:

 Established clear guidelines to determine patient compliance with recommendations of healthcare team (August 2010)

Responsible parties are Administrator, Transplant Program; Transplant Lead Social Worker

5. Improved Patient Management:


 Hired an additional physician assistant to support management of inpatients and to improved communication (September 2009)
 Instituted a new cardiac policy which states that all patients must be seen by a cardiologist at Albert Einstein Medical Center and have a final cardiac clearance at Albert Einstein Medical Center prior to going to the OR for transplant, and that all patients must have a yearly cardiac evaluation which includes a stress test, an echocardiolgram and a letter of clearance (January 2010)
 Improved infectious disease policy which highlights improved communication and more timely consults (January 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

6. Improved Team Communication:

 Purchased a transplant specific EMR (Transchart) (October 2007)
 Established a multidisciplinary meeting every Monday morning to discuss inpatient service and sign off (July 2008)
 Implemented a hospital wide clinical information system (July 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

7. Identify Risk Factors:

 Created a donor and recipient risk factor table to foster discussion among surgeons regarding those patients with multifactorial risks that outweigh the potential benefit from transplant (January 2011)
 Implemented an absolute and relative contraindication list for transplant chart (May 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

8. Improved Pharmaceutical Management

 Developed an enhanced immunosuppresion protocol (May 2011)
 Engaged transplant pharmacist in medication teaching to newly transplanted patients (June 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program; Transplant Pharmacist

9. Improved Peri Patient Care:

 Increased availability of local outpatient unit availability for expediting discharges for stable patients (November 2010)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

10. Improved Donor Management:

 Reduced cold ischemic time through improved coordination and communication among the surgical team (July 2008)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

11. Improved Live Donor Program:

 Engaged surgeon leadership in bimonthly live donor listing meeting (August 2010)
 Utilized flow cytometry for all live donors (June 2011)
Reduced unnecessary invasive testing by changing ordering practices for CT scans on live donors so that patient is medically cleared prior to testing (June 2011)

Responsible parties are Chairman, Division of Transplantation; Administrator, Transplant Program

12. Improved Post Care Followup:

 Created a followup mechanism for no-show patients to contact them and reschedule (July 2010)
 Worked with a specialty pharmacy affiliated with Albert Einstein Medical Center to provide continuity of care and increase communication and education with patients (August 2010)
 Transplant surgeons actively follow newly transplanted patients for one month form discharge in clinic (September 2010)
 Developed defined decision criteria for when to use prophylactic antibiotics and antifungals (October 2010)
Improved communication through the transplant specific EMR (January 2011)
Transplant Pharmacist participates in outpatient clinic for newly transplanted patients (June 2011)
Conducted weekly post multidisciplinary care meeting to discuss new transplants and patients seen in outpatient clinic (June 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant; Administrator, Transplant; Manager and Lead Data Coordinator

13. Improved accuracy of testing:

 Improved data entry with accurate reflection of risks by having a registered nurse confirm all UNet data entries (December 2010)

Responsible parties are Administrator, Transplant Program

14. Communication Enhancements:

 Implemented a new high risk donor alert on Transchart (EMR) (December 2010)
 Implemented a new H&P (January 2011)
Improved summary in Transchart (EMR) that a pre transplant nurse coordinator completes prior to transferring a patient from pre transplant to post transplant (January 2011)
 Mandated that two ABO's that a patient must have for listing must be completed at Albert Einstein Medical Center (February 2011)

Responsible parties are Administrator, Transplant Program; Manager and Lead Data Coordinator

15. Increased Resources:

 Completed renovation of Transplant space (August 2010)
 Hired a new HLA Lab Director (January 2011)
Hired a dedicated, full time transplant QAPI Nurse Manager (March 2011)
Hired a new transplant nephrologist (July 2011)
 Currently recruiting for an additional HLA lab technician (Ongoing)

Responsible parties are Administrator, Transplant Program; Vice President, Healthcare Services

16. Improved Outreach:

 Hired a social worker to actively do kidney outreach (January 2011)

Responsible parties are Administrator, Transplant Program

Based on these actions, there has been significant robust improvement in patient outcomes which has led to compliance with the expected outcome standards as demonstrated by the following data:
- There have been 63 kidney only transplants between January 1, 2010 and June 30, 2010 with 98% patient survival (there was 1 death) and 95% graft survival (there were 3 graft failures). This cohort has completed a full year since transplant.
- There have been 60 kidney only transplants between July 1, 2010 and December 31, 2010 with 93% patient survival (there were 4 deaths) and 98% graft survival (there was 1 graft failure).
- There have been 44 kidney only transplants between January 1, 2011 and June 30, 2011 with 100% patient survival and 98% graft survival (there was 1 graft failure).

CORRECTIVE ACTION PLAN LIVER LOWER THAN EXPECTED 1 YEAR PATIENT SURVIVAL

A full assessment of the liver transplant program including a detailed analysis of each event that led to a patient death and/or graft failure was completed in May 2010 The entire transplant program was evaluated by senior clinical and administrative leaders to look for opportunities for program improvement based on findings. Improvements were made at every phase of the transplant program including the following:
1) Quality Assessment:
- improved outcomes by monitoring past and present mortalities and graft losses through transplant specific M&M (May 2010)
- improved multidisciplinary engagement by increasing the frequency of discussion among multidisciplinary physician leaders (May 2010)
- audited outcomes on a monthly basis with senior leadership and audited monthly dashboard outcomes of rejection, infection, return to OR, LOS, and other complications (May 2010)
- improved communication between Transplant QAPI and Hospital QAPI by having a hospital QAPI representative at all transplant QAPI leadership meetings (June 2011)
- incorporated comprehensive QAPI committees and reporting into the functioning of the department: a) Monthly QAPI Leadership Committee b) Quarterly QAPI Council c) Monthly Transplant M&M meeting d) Weekly surgical M&M meeting e) Biannual Performance Improvement Council f) Quarterly QAPI with Anesthesia
Responsible parties are Administrator, Transplant Program; Transplant QAPI nurse manager
2) Improved patient evaluation/screening process accomplished through:
- improved listing meeting process (April 2010)
- improved discussion re: risks and benefits for individual patients being presented (August 2010)
- improved social work screening with individual contracts addressing the area of concern and/or noncompliance (May 2011)
- improved guidelines for addressing any work-up delays (July 2011)
- implemented a social work stratification list to identify absolute and relative contraindications to transplant (August 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Liver Transplant Program; Transplant Lead Social Worker
3) Improved Waitlist Management:
- standardized HCC management through weekly HCC meeting (July 2008)
- the pre transplant coordinator follows the patients who are wait listed for all of their hepatology needs (May 2010)
- increased drug/alcohol screenings for all admissions for liver patients on the waitlist, in evaluation, and those being considered for evaluation (March 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
4) Improved Patient Compliance:
- Established clear guidelines to determine patient compliance with recommendations of healthcare team (August 2010)
Responsible parties are Administrator, Transplant Program; Transplant Lead Social Worker
5) Improved Patient Management:
- hired an additional physician assistant to support management of inpatients and to improve communication (September 2009)
- instituted a new cardiac policy which states that all patients must be seen by a cardiologist at Albert Einstein Medical Center and have a final cardiac clearance at Albert Einstein Medical Center prior to going to OR for transplant, and that all patients must have a yearly cardiac evaluation which includes a stress test, an echocardiogram and a letter of clearance (January 2010)
- improved infectious disease policy which highlights improved communication and more timely consults (January 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
6) Improved Team Communication:
- purchased a transplant specific EMR (Transchart) (October 2007)
- established a multidisciplinary meeting every Monday morning to discuss inpatient service and sign off (July 2008)
- improved communication with radiology by having real time discussions attending to attending when a clinical situation for further discussion presents (July 2008)
- implemented a hospital wide clinical information system (July 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program; Lead Data Manager
7) Improved Donor Management:
- coordinated communication with surgical team to decrease cold ischemic time (July 2008)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
8) Identify Risk Factors:
- created a donor and recipient risk factor table to foster discussion among surgeons re: those patients with multifactorial risks that outweigh potential benefit from transplant (January 2011)
- implemented an absolute and relative contraindication list for transplant chart (February 2011)
- implemented the use of donor risk index (DRI) in evaluating risks of a particular organ (June 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
9) Improved Pharmaceutical Management:
- developed an enhanced immunosuppression protocol (May 2011)
- engaged transplant pharmacist in more formal medication teaching to newly transplanted patients (June 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program; Transplant Pharmacist
10) Procurements:
- An attending accompanies all fellows for procurements (April 2009)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
11) Inpatient Management:
- established a dedicated 17 bed unit for hepatology patients with specialty trained nurses in liver care (August 2011)
- maintain one ICU bed for hepatology patients that need to be transferred to our facility (August 2011
Responsible parties are Vice President Healthcare Services; Chief Nursing Officer
12) Improved Post Care follow-up:
- developed defined decision criteria for when to use prophylactic antibiotics and antifungal (July 2008)
- created a follow- up mechanism for no-show patients to contact them and reschedule (July 2010)
- worked with a specialty pharmacy affiliated with Albert Einstein Medical Center to provide continuity of care and increase communication and education with the patients (August 2010)
- established a protocol for all patients between 0-3 years post transplant to be seen by the transplant surgeon every 4 months (January 2011)
- improved communication through the transplant specific EMR (January 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program; Administrator, Transplant Program; Manager and Lead Data Coordinator
13) Improved accuracy of reporting:
- Improved data entry with accurate reflection of risks by having registered nurses confirm all UNet data entry (December 2010)
Responsible parties are Administrator, Transplant Program; Manager and Lead Data Coordinator
14) Communication Enhancements:
- implemented a new high risk donor alert on Transchart (EMR) (December 2010)
- implemented a new H/P (January 2011)
- mandated that the 2 ABO's that a patient must have for listing must be completed at Albert Einstein Medical Center (February 2011)
- implemented a Status 1 listing guideline and audit tool to provide clarification of a patient's status (July 2011)
Responsible parties are Administrator, Transplant Program; Manager and Lead Data Coordinator
15) Increased Resources:
- Completed renovation of transplant space (August 2010)
- Hired a new HLA lab director (January 2011)
- Hired a dedicated, full time transplant QAPI nurse manager (March 2011)
- opening of a satellite hepatology office to increase community referrals (September 2011)
- currently recruiting for an additional transplant hepatologist (ongoing)
- currently recruiting for an additional HLA lab technician (ongoing)
Responsible parties are Administrator Transplant Program; Vice President, Healthcare Services

Based on these actions, there has been significant robust improvement in patient outcomes which has led to compliance with the expected outcome standards as demonstrated by the following data:
 There have been eleven (11) liver transplants between 1/1/10 and 6/30/10 with 91% patient survival (there was one death). This cohort has completed full year since transplant.
 There have been fourteen (14) liver transplants between 7/1/10 and 12/31/10 with 86% patient survival (there were two deaths).
 There have been six (6) liver transplants between 1/1/11 and 6/30/11 with 100% patient survival.






482.82 CONDITION
DATA SUBMIT/EXPERIENCE/OUTCOMES - REAPPROVAL

Name - Component - 00 - Transplant Types: AKO, ALI

Except as specified in paragraph (d) of this section and 488.61 of this chapter, transplant centers must meet all data submission, clinical experience, and outcome requirements in order to be re-approved.



Observations:

Based on review by the Centers for Medicare & Medicaid Services (CMS) of the July 2011 outcomes calculated by the Scientific Registry of Transplant Recipients (SRTR), the Adult Kidney - Only (AKO) and the Adult Liver - Only (ALI) programs failed to ensure that the CMS outcome requirements were met for the one year post transplant graft survival rate for the AKO program and that the one year post transplant patient survival rates were met for the ALI program.

Findings include:

1) The AKO program's most recent outcomes data from the July 2011 SRTR Center Specific Report indicated that for patients receiving kidney transplants between January 1, 2008, and June 30, 2010, the observed graft failure rates within one year post transplant were higher than expected and considered unacceptable as outlined in X045.

See X045 for specific SRTR reported data results for graft failure rates.

2) The ALI program's mos recent outcomes data from he July 2011 SRTR Center Specific Report indicated that for patients receiving adult liver transplants between January 1, 2008, and June 30, 2010, the observed patient deaths within one year post transplant were higher than expected and considered unacceptable as outlined in X045.

See X045 for specific SRTR reported data results for patient survival rates.






Plan of Correction:

CORRECTIVE ACTION PLAN KIDNEY LOWER THAN EXPECETD 1 YEAR GRAFT SURVIVAL

A full assessment of the kidney transplant program including a detailed analysis of each event that led to a graft failure and/or mortality was completed in November 2010. The entire transplant program was evaluated by senior clinical and administrative leaders to look for opportunities for program improvement. Improvements were made at every phase of the transplant program including the following:

1. Quality Assessment


 Improved outcomes by monitoring past and present mortalities and graft losses through transplant specific M&M (May 2010)
 Improved multidisciplinary engagement by increasing the frequency of discussion among physician leaders (May 2010)
 Audited outcomes on a monthly basis with senior leadership and audited monthly dashboard of outcomes of rejection, infection, return to OR, LOS and other complications (July 2010)
 Improved communication between Transplant QAPI and Hospital QAPI by having a hospital QAPI representative at all transplant QAPI leadership meetings (June 2011)
 Incorporated comprehensive QAPI committees and reporting into the functioning of the department: a) Monthly QAPI Leadership Committee meeting b) Quarterly QAPI Council, c) Monthly Transplant M&M meeting d) Weekly surgical M&M meeting , e) Biannual Performance Improvement Council, f) Quarterly QAPI with Anesthesia

Responsible parties are Administrator, Transplant; Transplant QAPI Nurse Manager
2.
Improved patient evaluation/screening process:

 Improved listing meeting process (August 2010)
 Improved discussion re: risks and benefits for individual patients being presented (August 2010)
 Improved social work screening with individual contracts addressing the area of concern and/or noncompliance (May 2011)
 Pre transplant pharmacist assessment now available (June 2011)
 Required record review before evaluation for all patients who present with high risk factors (June 2011)
 Improved cardiology engagement through implementation of a cardiology risk stratification list when patients are e evaluated for a kidney transplant (July 2011)
 Implemented a social work stratification list to identify absolute and relative contraindications to transplant (August 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program; Transplant Lead Social Worker

3. Improved Waitlist Management

 Increased frequency of updating each wait list candidate (May 2010)
 All wait listed patients are seen for followup annually (May 2010)
 Hired a lead kidney transplant manager to oversee the management of the waitlist (May 2010)
 Implemented a bimonthly multidisciplinary review of the patients with the most time on the list or other factors that would make a candidate likely to be called in for transplant (June 2011)
 Quarterly review of patients 70 years of age and older (June 2011)

Responsible parties are Administrator, Transplant Program; Manager and Lead Kidney Coordinator

4. Improved Patient Compliance:

 Established clear guidelines to determine patient compliance with recommendations of healthcare team (August 2010)

Responsible parties are Administrator, Transplant Program; Transplant Lead Social Worker

5. Improved Patient Management:


 Hired an additional physician assistant to support management of inpatients and to improved communication (September 2009)
 Instituted a new cardiac policy which states that all patients must be seen by a cardiologist at Albert Einstein Medical Center and have a final cardiac clearance at Albert Einstein Medical Center prior to going to the OR for transplant, and that all patients must have a yearly cardiac evaluation which includes a stress test, an echocardiolgram and a letter of clearance (January 2010)
 Improved infectious disease policy which highlights improved communication and more timely consults (January 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

6. Improved Team Communication:

 Purchased a transplant specific EMR (Transchart) (October 2007)
 Established a multidisciplinary meeting every Monday morning to discuss inpatient service and sign off (July 2008)
 Implemented a hospital wide clinical information system (July 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

7. Identify Risk Factors:

 Created a donor and recipient risk factor table to foster discussion among surgeons regarding those patients with multifactorial risks that outweigh the potential benefit from transplant (January 2011)
 Implemented an absolute and relative contraindication list for transplant chart (May 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

8. Improved Pharmaceutical Management

 Developed an enhanced immunosuppresion protocol (May 2011)
 Engaged transplant pharmacist in medication teaching to newly transplanted patients (June 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program; Transplant Pharmacist

9. Improved Peri Patient Care:

 Increased availability of local outpatient unit availability for expediting discharges for stable patients (November 2010)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

10. Improved Donor Management:

 Reduced cold ischemic time through improved coordination and communication among the surgical team (July 2008)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

11. Improved Live Donor Program:

 Engaged surgeon leadership in bimonthly live donor listing meeting (August 2010)
 Utilized flow cytometry for all live donors (June 2011)
Reduced unnecessary invasive testing by changing ordering practices for CT scans on live donors so that patient is medically cleared prior to testing (June 2011)

Responsible parties are Chairman, Division of Transplantation; Administrator, Transplant Program

12. Improved Post Care Followup:

 Created a followup mechanism for no-show patients to contact them and reschedule (July 2010)
 Worked with a specialty pharmacy affiliated with Albert Einstein Medical Center to provide continuity of care and increase communication and education with patients (August 2010)
 Transplant surgeons actively follow newly transplanted patients for one month form discharge in clinic (September 2010)
 Developed defined decision criteria for when to use prophylactic antibiotics and antifungals (October 2010)
Improved communication through the transplant specific EMR (January 2011)
Transplant Pharmacist participates in outpatient clinic for newly transplanted patients (June 2011)
Conducted weekly post multidisciplinary care meeting to discuss new transplants and patients seen in outpatient clinic (June 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant; Administrator, Transplant; Manager and Lead Data Coordinator

13. Improved accuracy of testing:

 Improved data entry with accurate reflection of risks by having a registered nurse confirm all UNet data entries (December 2010)

Responsible parties are Administrator, Transplant Program

14. Communication Enhancements:

 Implemented a new high risk donor alert on Transchart (EMR) (December 2010)
 Implemented a new H&P (January 2011)
Improved summary in Transchart (EMR) that a pre transplant nurse coordinator completes prior to transferring a patient from pre transplant to post transplant (January 2011)
 Mandated that two ABO's that a patient must have for listing must be completed at Albert Einstein Medical Center (February 2011)

Responsible parties are Administrator, Transplant Program; Manager and Lead Data Coordinator

15. Increased Resources:

 Completed renovation of Transplant space (August 2010)
 Hired a new HLA Lab Director (January 2011)
Hired a dedicated, full time transplant QAPI Nurse Manager (March 2011)
Hired a new transplant nephrologist (July 2011)
 Currently recruiting for an additional HLA lab technician (Ongoing)

Responsible parties are Administrator, Transplant Program; Vice President, Healthcare Services

16. Improved Outreach:

 Hired a social worker to actively do kidney outreach (January 2011)

Responsible parties are Administrator, Transplant Program

Based on these actions, there has been significant robust improvement in patient outcomes which has led to compliance with the expected outcome standards as demonstrated by the following data:
- There have been 63 kidney only transplants between January 1, 2010 and June 30, 2010 with 98% patient survival (there was 1 death) and 95% graft survival (there were 3 graft failures). This cohort has completed a full year since transplant.
- There have been 60 kidney only transplants between July 1, 2010 and December 31, 2010 with 93% patient survival (there were 4 deaths) and 98% graft survival (there was 1 graft failure).
- There have been 44 kidney only transplants between January 1, 2011 and June 30, 2011 with 100% patient survival and 98% graft survival (there was 1 graft failure).

CORRECTIVE ACTION PLAN LIVER LOWER THAN EXPECTED 1 YEAR PATIENT SURVIVAL

A full assessment of the liver transplant program including a detailed analysis of each event that led to a patient death and/or graft failure was completed in May 2010 The entire transplant program was evaluated by senior clinical and administrative leaders to look for opportunities for program improvement based on findings. Improvements were made at every phase of the transplant program including the following:
1) Quality Assessment:
- improved outcomes by monitoring past and present mortalities and graft losses through transplant specific M&M (May 2010)
- improved multidisciplinary engagement by increasing the frequency of discussion among multidisciplinary physician leaders (May 2010)
- audited outcomes on a monthly basis with senior leadership and audited monthly dashboard outcomes of rejection, infection, return to OR, LOS, and other complications (May 2010)
- improved communication between Transplant QAPI and Hospital QAPI by having a hospital QAPI representative at all transplant QAPI leadership meetings (June 2011)
- incorporated comprehensive QAPI committees and reporting into the functioning of the department: a) Monthly QAPI Leadership Committee b) Quarterly QAPI Council c) Monthly Transplant M&M meeting d) Weekly surgical M&M meeting e) Biannual Performance Improvement Council f) Quarterly QAPI with Anesthesia
Responsible parties are Administrator, Transplant Program; Transplant QAPI nurse manager
2) Improved patient evaluation/screening process accomplished through:
- improved listing meeting process (April 2010)
- improved discussion re: risks and benefits for individual patients being presented (August 2010)
- improved social work screening with individual contracts addressing the area of concern and/or noncompliance (May 2011)
- improved guidelines for addressing any work-up delays (July 2011)
- implemented a social work stratification list to identify absolute and relative contraindications to transplant (August 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Liver Transplant Program; Transplant Lead Social Worker
3) Improved Waitlist Management:
- standardized HCC management through weekly HCC meeting (July 2008)
- the pre transplant coordinator follows the patients who are wait listed for all of their hepatology needs (May 2010)
- increased drug/alcohol screenings for all admissions for liver patients on the waitlist, in evaluation, and those being considered for evaluation (March 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
4) Improved Patient Compliance:
- Established clear guidelines to determine patient compliance with recommendations of healthcare team (August 2010)
Responsible parties are Administrator, Transplant Program; Transplant Lead Social Worker
5) Improved Patient Management:
- hired an additional physician assistant to support management of inpatients and to improve communication (September 2009)
- instituted a new cardiac policy which states that all patients must be seen by a cardiologist at Albert Einstein Medical Center and have a final cardiac clearance at Albert Einstein Medical Center prior to going to OR for transplant, and that all patients must have a yearly cardiac evaluation which includes a stress test, an echocardiogram and a letter of clearance (January 2010)
- improved infectious disease policy which highlights improved communication and more timely consults (January 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
6) Improved Team Communication:
- purchased a transplant specific EMR (Transchart) (October 2007)
- established a multidisciplinary meeting every Monday morning to discuss inpatient service and sign off (July 2008)
- improved communication with radiology by having real time discussions attending to attending when a clinical situation for further discussion presents (July 2008)
- implemented a hospital wide clinical information system (July 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program; Lead Data Manager
7) Improved Donor Management:
- coordinated communication with surgical team to decrease cold ischemic time (July 2008)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
8) Identify Risk Factors:
- created a donor and recipient risk factor table to foster discussion among surgeons re: those patients with multifactorial risks that outweigh potential benefit from transplant (January 2011)
- implemented an absolute and relative contraindication list for transplant chart (February 2011)
- implemented the use of donor risk index (DRI) in evaluating risks of a particular organ (June 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
9) Improved Pharmaceutical Management:
- developed an enhanced immunosuppression protocol (May 2011)
- engaged transplant pharmacist in more formal medication teaching to newly transplanted patients (June 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program; Transplant Pharmacist
10) Procurements:
- An attending accompanies all fellows for procurements (April 2009)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
11) Inpatient Management:
- established a dedicated 17 bed unit for hepatology patients with specialty trained nurses in liver care (August 2011)
- maintain one ICU bed for hepatology patients that need to be transferred to our facility (August 2011
Responsible parties are Vice President Healthcare Services; Chief Nursing Officer
12) Improved Post Care follow-up:
- developed defined decision criteria for when to use prophylactic antibiotics and antifungal (July 2008)
- created a follow- up mechanism for no-show patients to contact them and reschedule (July 2010)
- worked with a specialty pharmacy affiliated with Albert Einstein Medical Center to provide continuity of care and increase communication and education with the patients (August 2010)
- established a protocol for all patients between 0-3 years post transplant to be seen by the transplant surgeon every 4 months (January 2011)
- improved communication through the transplant specific EMR (January 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program; Administrator, Transplant Program; Manager and Lead Data Coordinator
13) Improved accuracy of reporting:
- Improved data entry with accurate reflection of risks by having registered nurses confirm all UNet data entry (December 2010)
Responsible parties are Administrator, Transplant Program; Manager and Lead Data Coordinator
14) Communication Enhancements:
- implemented a new high risk donor alert on Transchart (EMR) (December 2010)
- implemented a new H/P (January 2011)
- mandated that the 2 ABO's that a patient must have for listing must be completed at Albert Einstein Medical Center (February 2011)
- implemented a Status 1 listing guideline and audit tool to provide clarification of a patient's status (July 2011)
Responsible parties are Administrator, Transplant Program; Manager and Lead Data Coordinator
15) Increased Resources:
- Completed renovation of transplant space (August 2010)
- Hired a new HLA lab director (January 2011)
- Hired a dedicated, full time transplant QAPI nurse manager (March 2011)
- opening of a satellite hepatology office to increase community referrals (September 2011)
- currently recruiting for an additional transplant hepatologist (ongoing)
- currently recruiting for an additional HLA lab technician (ongoing)
Responsible parties are Administrator Transplant Program; Vice President, Healthcare Services

Based on these actions, there has been significant robust improvement in patient outcomes which has led to compliance with the expected outcome standards as demonstrated by the following data:
 There have been eleven (11) liver transplants between 1/1/10 and 6/30/10 with 91% patient survival (there was one death). This cohort has completed full year since transplant.
 There have been fourteen (14) liver transplants between 7/1/10 and 12/31/10 with 86% patient survival (there were two deaths).
 There have been six (6) liver transplants between 1/1/11 and 6/30/11 with 100% patient survival.






482.82(c)(3) ELEMENT
OUTCOME: PATIENT/GRAFT SURVIVAL - REAPPROVAL

Name - Component - 00 - Transplant Types: AKO, ALI

CMS will not consider a center's patient and graft survival rates to be acceptable if: (i) A center's observed patient survival rate or observed graft survival rate is lower than its expected patient survival rate and graft survival rate; and (ii) All three of the following thresholds are crossed over: (A) The one-sided p-value is less than 0.05, (B) The number of observed events (patient deaths or graft failures) minus the number of expected events is greater than 3, and (C) The number of observed events divided by the number of expected events is greater than 1.5.





Observations:

Based on review of data from the July 2011 Scientific Registry of Transplant Recipients (SRTR) Center Specific Report, the Adult Kidney - Only (AKO) program did not meet the regulatory outcome requirements outlines in CFR 482.82 (c) (3) for one year graft survival rates and that the Adult Liver - Only (ALI) program did not meet the one year patient survival rates.

Findings include:

1) Review of the SRTR risk - adjusted outcomes report dated July 2011 revealed that the actual one year graft survival rate for the AKO program was significantly lower than expected for patients transplanted between January 1, 2008, and June 30, 2010. The expected number of graft failures (based on patient and donor characteristics) was 22.11; the actual number of graft failures was 35. This is a statistically significant difference (i.e., p-value is 0.007). In addition, the AKO program had significantly lower than expected outcomes in one of four prior SRTR reports (January 2011).

2) Review of the SRTR risk - adjusted outcomes report dated July 2011 revealed that the actual one year patient survival rates for the ALI program was significantly lower than expected for patients transplanted between January 1, 2008, and June 30, 2010. The expected number of patient deaths within one year post transplant (based on patient and donor characteristics) was 6.43; the actual number of patient deaths within one year post transplant was 13. This is a statistically significant difference (i.e., p-value is 0.015). In addition the ALI program had significantly lower than expected outcomes in one of the four prior SRTR reports (January 2011).





Plan of Correction:

CORRECTIVE ACTION PLAN KIDNEY LOWER THAN EXPECETD 1 YEAR GRAFT SURVIVAL

A full assessment of the kidney transplant program including a detailed analysis of each event that led to a graft failure and/or mortality was completed in November 2010. The entire transplant program was evaluated by senior clinical and administrative leaders to look for opportunities for program improvement. Improvements were made at every phase of the transplant program including the following:

1. Quality Assessment


 Improved outcomes by monitoring past and present mortalities and graft losses through transplant specific M&M (May 2010)
 Improved multidisciplinary engagement by increasing the frequency of discussion among physician leaders (May 2010)
 Audited outcomes on a monthly basis with senior leadership and audited monthly dashboard of outcomes of rejection, infection, return to OR, LOS and other complications (July 2010)
 Improved communication between Transplant QAPI and Hospital QAPI by having a hospital QAPI representative at all transplant QAPI leadership meetings (June 2011)
 Incorporated comprehensive QAPI committees and reporting into the functioning of the department: a) Monthly QAPI Leadership Committee meeting b) Quarterly QAPI Council, c) Monthly Transplant M&M meeting d) Weekly surgical M&M meeting , e) Biannual Performance Improvement Council, f) Quarterly QAPI with Anesthesia

Responsible parties are Administrator, Transplant; Transplant QAPI Nurse Manager
2.
Improved patient evaluation/screening process:

 Improved listing meeting process (August 2010)
 Improved discussion re: risks and benefits for individual patients being presented (August 2010)
 Improved social work screening with individual contracts addressing the area of concern and/or noncompliance (May 2011)
 Pre transplant pharmacist assessment now available (June 2011)
 Required record review before evaluation for all patients who present with high risk factors (June 2011)
 Improved cardiology engagement through implementation of a cardiology risk stratification list when patients are e evaluated for a kidney transplant (July 2011)
 Implemented a social work stratification list to identify absolute and relative contraindications to transplant (August 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program; Transplant Lead Social Worker

3. Improved Waitlist Management

 Increased frequency of updating each wait list candidate (May 2010)
 All wait listed patients are seen for followup annually (May 2010)
 Hired a lead kidney transplant manager to oversee the management of the waitlist (May 2010)
 Implemented a bimonthly multidisciplinary review of the patients with the most time on the list or other factors that would make a candidate likely to be called in for transplant (June 2011)
 Quarterly review of patients 70 years of age and older (June 2011)

Responsible parties are Administrator, Transplant Program; Manager and Lead Kidney Coordinator

4. Improved Patient Compliance:

 Established clear guidelines to determine patient compliance with recommendations of healthcare team (August 2010)

Responsible parties are Administrator, Transplant Program; Transplant Lead Social Worker

5. Improved Patient Management:


 Hired an additional physician assistant to support management of inpatients and to improved communication (September 2009)
 Instituted a new cardiac policy which states that all patients must be seen by a cardiologist at Albert Einstein Medical Center and have a final cardiac clearance at Albert Einstein Medical Center prior to going to the OR for transplant, and that all patients must have a yearly cardiac evaluation which includes a stress test, an echocardiolgram and a letter of clearance (January 2010)
 Improved infectious disease policy which highlights improved communication and more timely consults (January 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

6. Improved Team Communication:

 Purchased a transplant specific EMR (Transchart) (October 2007)
 Established a multidisciplinary meeting every Monday morning to discuss inpatient service and sign off (July 2008)
 Implemented a hospital wide clinical information system (July 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

7. Identify Risk Factors:

 Created a donor and recipient risk factor table to foster discussion among surgeons regarding those patients with multifactorial risks that outweigh the potential benefit from transplant (January 2011)
 Implemented an absolute and relative contraindication list for transplant chart (May 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

8. Improved Pharmaceutical Management

 Developed an enhanced immunosuppresion protocol (May 2011)
 Engaged transplant pharmacist in medication teaching to newly transplanted patients (June 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program; Transplant Pharmacist

9. Improved Peri Patient Care:

 Increased availability of local outpatient unit availability for expediting discharges for stable patients (November 2010)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

10. Improved Donor Management:

 Reduced cold ischemic time through improved coordination and communication among the surgical team (July 2008)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant Program

11. Improved Live Donor Program:

 Engaged surgeon leadership in bimonthly live donor listing meeting (August 2010)
 Utilized flow cytometry for all live donors (June 2011)
Reduced unnecessary invasive testing by changing ordering practices for CT scans on live donors so that patient is medically cleared prior to testing (June 2011)

Responsible parties are Chairman, Division of Transplantation; Administrator, Transplant Program

12. Improved Post Care Followup:

 Created a followup mechanism for no-show patients to contact them and reschedule (July 2010)
 Worked with a specialty pharmacy affiliated with Albert Einstein Medical Center to provide continuity of care and increase communication and education with patients (August 2010)
 Transplant surgeons actively follow newly transplanted patients for one month form discharge in clinic (September 2010)
 Developed defined decision criteria for when to use prophylactic antibiotics and antifungals (October 2010)
Improved communication through the transplant specific EMR (January 2011)
Transplant Pharmacist participates in outpatient clinic for newly transplanted patients (June 2011)
Conducted weekly post multidisciplinary care meeting to discuss new transplants and patients seen in outpatient clinic (June 2011)

Responsible parties are Chairman, Division of Transplantation; Medical Director, Kidney Transplant; Administrator, Transplant; Manager and Lead Data Coordinator

13. Improved accuracy of testing:

 Improved data entry with accurate reflection of risks by having a registered nurse confirm all UNet data entries (December 2010)

Responsible parties are Administrator, Transplant Program

14. Communication Enhancements:

 Implemented a new high risk donor alert on Transchart (EMR) (December 2010)
 Implemented a new H&P (January 2011)
Improved summary in Transchart (EMR) that a pre transplant nurse coordinator completes prior to transferring a patient from pre transplant to post transplant (January 2011)
 Mandated that two ABO's that a patient must have for listing must be completed at Albert Einstein Medical Center (February 2011)

Responsible parties are Administrator, Transplant Program; Manager and Lead Data Coordinator

15. Increased Resources:

 Completed renovation of Transplant space (August 2010)
 Hired a new HLA Lab Director (January 2011)
Hired a dedicated, full time transplant QAPI Nurse Manager (March 2011)
Hired a new transplant nephrologist (July 2011)
 Currently recruiting for an additional HLA lab technician (Ongoing)

Responsible parties are Administrator, Transplant Program; Vice President, Healthcare Services

16. Improved Outreach:

 Hired a social worker to actively do kidney outreach (January 2011)

Responsible parties are Administrator, Transplant Program

Based on these actions, there has been significant robust improvement in patient outcomes which has led to compliance with the expected outcome standards as demonstrated by the following data:
- There have been 63 kidney only transplants between January 1, 2010 and June 30, 2010 with 98% patient survival (there was 1 death) and 95% graft survival (there were 3 graft failures). This cohort has completed a full year since transplant.
- There have been 60 kidney only transplants between July 1, 2010 and December 31, 2010 with 93% patient survival (there were 4 deaths) and 98% graft survival (there was 1 graft failure).
- There have been 44 kidney only transplants between January 1, 2011 and June 30, 2011 with 100% patient survival and 98% graft survival (there was 1 graft failure).

CORRECTIVE ACTION PLAN LIVER LOWER THAN EXPECTED 1 YEAR PATIENT SURVIVAL

A full assessment of the liver transplant program including a detailed analysis of each event that led to a patient death and/or graft failure was completed in May 2010 The entire transplant program was evaluated by senior clinical and administrative leaders to look for opportunities for program improvement based on findings. Improvements were made at every phase of the transplant program including the following:
1) Quality Assessment:
- improved outcomes by monitoring past and present mortalities and graft losses through transplant specific M&M (May 2010)
- improved multidisciplinary engagement by increasing the frequency of discussion among multidisciplinary physician leaders (May 2010)
- audited outcomes on a monthly basis with senior leadership and audited monthly dashboard outcomes of rejection, infection, return to OR, LOS, and other complications (May 2010)
- improved communication between Transplant QAPI and Hospital QAPI by having a hospital QAPI representative at all transplant QAPI leadership meetings (June 2011)
- incorporated comprehensive QAPI committees and reporting into the functioning of the department: a) Monthly QAPI Leadership Committee b) Quarterly QAPI Council c) Monthly Transplant M&M meeting d) Weekly surgical M&M meeting e) Biannual Performance Improvement Council f) Quarterly QAPI with Anesthesia
Responsible parties are Administrator, Transplant Program; Transplant QAPI nurse manager
2) Improved patient evaluation/screening process accomplished through:
- improved listing meeting process (April 2010)
- improved discussion re: risks and benefits for individual patients being presented (August 2010)
- improved social work screening with individual contracts addressing the area of concern and/or noncompliance (May 2011)
- improved guidelines for addressing any work-up delays (July 2011)
- implemented a social work stratification list to identify absolute and relative contraindications to transplant (August 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Liver Transplant Program; Transplant Lead Social Worker
3) Improved Waitlist Management:
- standardized HCC management through weekly HCC meeting (July 2008)
- the pre transplant coordinator follows the patients who are wait listed for all of their hepatology needs (May 2010)
- increased drug/alcohol screenings for all admissions for liver patients on the waitlist, in evaluation, and those being considered for evaluation (March 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
4) Improved Patient Compliance:
- Established clear guidelines to determine patient compliance with recommendations of healthcare team (August 2010)
Responsible parties are Administrator, Transplant Program; Transplant Lead Social Worker
5) Improved Patient Management:
- hired an additional physician assistant to support management of inpatients and to improve communication (September 2009)
- instituted a new cardiac policy which states that all patients must be seen by a cardiologist at Albert Einstein Medical Center and have a final cardiac clearance at Albert Einstein Medical Center prior to going to OR for transplant, and that all patients must have a yearly cardiac evaluation which includes a stress test, an echocardiogram and a letter of clearance (January 2010)
- improved infectious disease policy which highlights improved communication and more timely consults (January 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
6) Improved Team Communication:
- purchased a transplant specific EMR (Transchart) (October 2007)
- established a multidisciplinary meeting every Monday morning to discuss inpatient service and sign off (July 2008)
- improved communication with radiology by having real time discussions attending to attending when a clinical situation for further discussion presents (July 2008)
- implemented a hospital wide clinical information system (July 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program; Lead Data Manager
7) Improved Donor Management:
- coordinated communication with surgical team to decrease cold ischemic time (July 2008)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
8) Identify Risk Factors:
- created a donor and recipient risk factor table to foster discussion among surgeons re: those patients with multifactorial risks that outweigh potential benefit from transplant (January 2011)
- implemented an absolute and relative contraindication list for transplant chart (February 2011)
- implemented the use of donor risk index (DRI) in evaluating risks of a particular organ (June 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
9) Improved Pharmaceutical Management:
- developed an enhanced immunosuppression protocol (May 2011)
- engaged transplant pharmacist in more formal medication teaching to newly transplanted patients (June 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program; Transplant Pharmacist
10) Procurements:
- An attending accompanies all fellows for procurements (April 2009)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program
11) Inpatient Management:
- established a dedicated 17 bed unit for hepatology patients with specialty trained nurses in liver care (August 2011)
- maintain one ICU bed for hepatology patients that need to be transferred to our facility (August 2011
Responsible parties are Vice President Healthcare Services; Chief Nursing Officer
12) Improved Post Care follow-up:
- developed defined decision criteria for when to use prophylactic antibiotics and antifungal (July 2008)
- created a follow- up mechanism for no-show patients to contact them and reschedule (July 2010)
- worked with a specialty pharmacy affiliated with Albert Einstein Medical Center to provide continuity of care and increase communication and education with the patients (August 2010)
- established a protocol for all patients between 0-3 years post transplant to be seen by the transplant surgeon every 4 months (January 2011)
- improved communication through the transplant specific EMR (January 2011)
Responsible parties are Chairman, Division of Transplantation; Chief, Division of Liver Transplant; Medical Director, Liver Transplant Program; Administrator, Transplant Program; Manager and Lead Data Coordinator
13) Improved accuracy of reporting:
- Improved data entry with accurate reflection of risks by having registered nurses confirm all UNet data entry (December 2010)
Responsible parties are Administrator, Transplant Program; Manager and Lead Data Coordinator
14) Communication Enhancements:
- implemented a new high risk donor alert on Transchart (EMR) (December 2010)
- implemented a new H/P (January 2011)
- mandated that the 2 ABO's that a patient must have for listing must be completed at Albert Einstein Medical Center (February 2011)
- implemented a Status 1 listing guideline and audit tool to provide clarification of a patient's status (July 2011)
Responsible parties are Administrator, Transplant Program; Manager and Lead Data Coordinator
15) Increased Resources:
- Completed renovation of transplant space (August 2010)
- Hired a new HLA lab director (January 2011)
- Hired a dedicated, full time transplant QAPI nurse manager (March 2011)
- opening of a satellite hepatology office to increase community referrals (September 2011)
- currently recruiting for an additional transplant hepatologist (ongoing)
- currently recruiting for an additional HLA lab technician (ongoing)
Responsible parties are Administrator Transplant Program; Vice President, Healthcare Services

Based on these actions, there has been significant robust improvement in patient outcomes which has led to compliance with the expected outcome standards as demonstrated by the following data:
 There have been eleven (11) liver transplants between 1/1/10 and 6/30/10 with 91% patient survival (there was one death). This cohort has completed full year since transplant.
 There have been fourteen (14) liver transplants between 7/1/10 and 12/31/10 with 86% patient survival (there were two deaths).
 There have been six (6) liver transplants between 1/1/11 and 6/30/11 with 100% patient survival.