Quality: Distinctive Characteristics of Excellence and Patient Safety

1. Quality: Distinctive Characteristics of Excellence and Patient Safety Linda Ohler, MSN, RN, CCTC, FAANTransplant Quality and Regulatory Manager George Washington University Hospital Transplant Institute

2. Objectives • Describe how we came to focus on quality in transplantation • Discuss how the focus on quality has increased patient safety and outcomes in our field. • Explain the changes that have occurred in outcomes since 2007

3. Overview and Zoo Preview

4. Brazil 6 presentations 2 days Back to US on Day 3

5. Once upon a time in transplantation • Little or no oversight

6. Transplant: Flying Under the Radar

7. Describe how we came to focus on quality in transplantation

8. Then along came Charles Ornstein and Tracy Weber

9. U.S. organ network routinely fails to detect problems. By Charles Ornstein and Tracy WeberOctober 22, 2006

11. Broad failings documented at agencies overseeing organ transplants By Charles Ornstein and Tracy WeberMay 19, 2008

12. Enter: Senator Grassley Government Accounting Office

13. Why did we need to be regulated? • 2005 GAO reported that transplant programs were not adequately regulated (Senator Grassley) • CMS Conditions of Participation 2007 • SRTR releases

14. Waitlist Management • A Third of Patients On Transplant List Are Not Eligible By Rob SteinWashington Post Staff Writer Saturday, March 22, 2008

15. BeiBeiand BaoBao Birthday at National Zoo in DC

16. CMS Conditions of Participation for Transplant Programs June 2007

17. Explain the changes that have occurred since 2007

18. Number of Medicare-Approved Transplant Hospitals 1 WA 5 VT:1 0 ME 2 7 ND 1 2 MT NH 15 4 0 OR 1 MN SD 10 NY ID 0 WI MI 25 17 MA: 10 4 PA WY 2 6 2 IA 10 RI: 1 3 8 NE OH MD 2 CT:2 IN 2 4 7 10 WV UT 2 IL 3 VA DE:1 NV CO KS KY MO 6 MD:2 11 NC 4 5 TN DC: 4 2 3 1 CA OK SC 6 AR 2 AZ 1 0 NM AL GA 25 6 MS AK LA 1 10 Number of Transplant Hospital Centers Pink: 0 Orange: 1-9 Green: 10-20 Blue: 21-30 FL TX PR:2 18

19. UNOS and CMS begin surveys • Policy development • Do policies match practice? • Do we have policies to reflect all the COPs? • Quality not a focus in 2008-9 surveys • Many inconsistencies with state surveyors

20. Transplant Surveys • UNOS • Planned 3 day site visits • List of patients given 1 month ahead • Follow up with desk audits • All go to MPSC for decisions • UNOS • Living donor surveys • List of donors and recipients • 3 day site visits • CMS • Unannounced visit • Usually 5-7 days • Focus is on quality, performance improvement and outcomes • Joint Commission • Disease Specific programs • VAD (planned visits) • Lung • Not deemed authority for transplant yet.

21. Were the policies clear?

22. Explain the changes that have occurred since 2007 • 2015 UNOS and CMS have worked together to create one voice in terms of policies • UNOS educational Webinars • AST provides CMS Webinars • QAPI education programs • TQI • Data software (OTTR)

23. Why the focus on patient safety? • IOM To Err is Human in 1999 • 98,000 patient deaths per year (estimated) • 2013 • 440,000 deaths to patients in hospitals

24. Why the focus on patient safety?

25. Human Error vs Technology • Systems do not communicate • CERNER • ALLSCRIPTS • OTTR • Surginet • MIDAS • XYNQAPI

26. Discuss how the focus on quality has increased patient safety and outcomes in our field.

27. CMS July 2016 Federal Register • Between 2007 and 2015: • 145 programs cited for deficiencies • Patient or graft volumes • Outcomes below expected • 83 improved within the 210 day period • Outcomes • Performance improvements • 45 completed a 1 year SIA • 17 terminated Medicare participation

28. CMS July 2016 Federal Register • One year patient outcomes have improved since 2007 • Transplant programs involved in performance improvement projects • Education on • How to implement PI projects • How to develop scorecards • Data integrity • Data analysis • Performing a root cause analysis • Evaluating systems • Avoiding personal blame

29. How has the focus on quality increased patient safety? • Root cause analysis Vs Morbidity and mortality • QAPI Plans • Policies • Grass roots policies • Patient safety portal at UNOS • Focus on outcomes • Patient and graft survival • Focus on patient selection • (I like this patient!)

30. What are some of the initiatives that have created a safer patient environment? • Structure for programs • ABO Verifications • Organ check in • SRTR reports to the public every 6 months • Insurers too • QAPI focus • Educational programs on Quality • Webinars • Consultants • Patient safety events portal on Unet • Education of clinicians on safety

31. We have all felt pressured, angry, cranky about all the rules and regulations ……

32. However….. Outcomes are improving

33. How has the focus on quality increased patient safety? • Outcomes have increased for: • Heart transplant patient survival from 88.5 to 89.5% one year • Adult Kidney graft survival from 92.9 in 2007 to 94.8 in 2014 • Liver recipients patient survival increased from 87.7 to 90.8 • Lung recipient patient survival increased from 80.4 % to 85.7%

34. And the oversight continues to tighten! Scorecards/Benchmarking/Defining Audits/PI Projects SRTR/CUSUM/Bayesian/O/E Thorough Analysis vs Root Cause Analysis

35. 2017 Proposed Rule for Cost Efficiency • Hospital readmission reduction • Reduction of hospital acquired conditions • Hospital-based Inpatient Psychiatric Services Quality Reporting Program • Hospital Inpatient Quality Reporting Program (discharge) • Hospital Value-Based Purchasing Program

36. More performance measures? Really??

37. But our partners continue to work with us

38. OTTR Partners

39. Lied Jungle at Omaha Zoo

40. Thank you

41. Enjoy the Henry Doorly Zoo