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201611307

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Policies,Administrative,UWHC,Department Specific,Transplant,QAPI

Transplant Quality Assurance and Process Improvement (QAPI) Policy (6.0)

Transplant Quality Assurance and Process Improvement (QAPI) Policy (6.0) - Policies, Administrative, UWHC, Department Specific, Transplant, QAPI

6.0



POLICY & PROCEDURE
Effective Date: October 2016
Revised Date: October 2016
Title: Transplant Quality Assurance and Process
improvement (QAPI) Policy
Policy Number: 6.0

Page 1 of 5
I. PURPOSE
The purpose of this policy is to ensure that UW Transplant maintains a transplant-specific Quality
Assurance and Process Improvement (QAPI) program that is comprehensive and data-driven. The
QAPI program effectively evaluates individual program services through objective data analysis,
implementation of performance improvements, and management of transplant adverse events, to
ensure the safety of transplant candidates, recipients, and living donors across the continuum of
care. The transplant specific QAPI program monitors outcomes of patients in all phases of
transplant including living donors.

II. POLICY
It is the policy of UW Transplant to adhere to the UW Health standards of patient care, as well as
the standards determined by regulatory and accrediting agencies, such as The Joint Commission
(TJC), the Organ Procurement and Transplantation Network/United Network for Organ Sharing
(UNOS/OPTN), and the Centers for Medicare & Medicaid Services (CMS).

III. DEFINITIONS
• A3: Template used to document performance improvement initiatives
• FOCUS-PDCA: Improvement methodology used by UW Health (Find a process to improve,
Organize a team, Clarify current state, Understand root causes, Select an improvement, Plan-Do-
Check-Act)
• HLA: Histocompatibility Laboratory
• OR: Operating Room
• QAPI: Quality Assurance and Process Improvement
• SRTR: Scientific Registry of Transplant Recipients
• UWHCA: University of Wisconsin Hospitals and Clinics Authority
• UWHIN: UW Health Improvement Network
• VA: Veterans Administration

IV. PROCEDURES
A. QAPI Program Oversight
The primary oversight of the Transplant QAPI Program is the Transplant QAPI Steering
Committee.
1. Membership of the Transplant QAPI Steering Committee:
• Medical Director, Transplant Service Line
• Director, Transplant Service Line
• Program Director, Performance Excellence
• Transplant Operations Director



POLICY & PROCEDURE
Effective Date: October 2016
Revised Date: October 2016
Title: Transplant Quality Assurance and Process
improvement (QAPI) Policy
Policy Number: 6.0

Page 2 of 5
• Program-Specific Transplant Surgical and Medical Directors
• Chief Operating Officer, UW Hospitals and Clinics
• Program-Specific Clinical Managers
• Transplant Clinic Manager
• Inpatient Transplant Managers
• Leadership Representatives from: OR, HLA, VA, & Pharmacy
• Hospital Quality Leadership
 Vice President of Quality and Safety, Director of Quality, Quality Improvement
Specialist
• Multidisciplinary Staff Representatives
 Social Worker, Dietician, Transplant Coordinator, Advanced Practice
Providers, etc.
2. Responsibilities of the Transplant QAPI Steering Committee:
• Oversee the execution of and provide ongoing monitoring of the QAPI plan
• Review and update the QAPI plan on an annual basis
• Review highlighted performance improvement projects for UW Transplant
• Review trended patient safety data for each transplant program
• Ensure regulatory readiness of all transplant programs
• Ensure bi-directional communication between UW Transplant and UW Health
regarding quality initiatives and data
3. Meeting Frequency:
The Transplant QAPI Steering Committee meets on a quarterly basis. Meeting slides are
compiled in advance of the meeting. Attendance is taken during the meeting on a sign-in
sheet. Minutes are taken during the meeting and distributed to all participants via email
after the meeting.

B. Program-Specific QAPI Leadership Committees
Program-specific QAPI leadership meetings occur to evaluate program-specific performance.
1. Membership of the Program-Specific QAPI Leadership Committees:
• Surgical Director
• Medical Director
• Clinical Manager
• Transplant Director
• Others may include: Performance Excellence Program Director, Data Manager,
Regulatory Specialist, other clinical staff, physicians and surgeons





POLICY & PROCEDURE
Effective Date: October 2016
Revised Date: October 2016
Title: Transplant Quality Assurance and Process
improvement (QAPI) Policy
Policy Number: 6.0

Page 3 of 5
2. Responsibilities of the Program-Specific QAPI Leadership Committees:
• Analyze program-specific objective measures targeting key performance
indicators that reflect patient safety, processes, outcomes, regulatory
requirements, and clinical progress
• Analyze identified data points or trends and initiate process improvement
projects as needed
• Form workgroups and utilize the FOCUS PDCA methodology and UWHIN tools to
make improvements and document in the A3 template
3. Meeting Frequency:
The program-specific QAPI teams meet a minimum of a quarterly basis, depending on
the size of the program. Standard templates are utilized to share program-specific
objective measures, including patient safety data and performance improvement
initiatives. Minutes are kept electronically to document the meetings.

C. QAPI Plan
The primary document summarizing all activities of the comprehensive Transplant QAPI
program is the Transplant QAPI plan.
1. Review Frequency:
The Transplant QAPI plan is reviewed by all members of the Transplant QAPI Steering
Committee to ensure all content reflects current practice and is compliant with
regulations. This review occurs at a minimum of an annual fiscal year basis. The new
fiscal year begins on July 1 of each year and ends on June 30.
2. Approval Process:
The Transplant QAPI plan is first approved by the Medical Director of the Transplant
Service Line, the Administrative Director of the Transplant Service Line, and the UW
Hospitals and Clinics Chief Operating Officer. The plan is then approved by the Patient
Safety and Quality Committee of the UW Hospital and Clinics Authority Board of
Directors.
3. Communication:
The final, approved Transplant QAPI plan is communicated to the Transplant QAPI
Steering Committee. The final version is posted on the Transplant UConnect website for
easy access by all UW Health staff.









POLICY & PROCEDURE
Effective Date: October 2016
Revised Date: October 2016
Title: Transplant Quality Assurance and Process
improvement (QAPI) Policy
Policy Number: 6.0

Page 4 of 5
D. QAPI Communication
The UW Transplant QAPI program utilizes bi-direction communication to ensure the transplant
and hospital QAPI activities are functionally integrated.
1. Transplant to Hospital:
• The Hospital Quality and Transplant Leadership team comprised of the Vice
President of Quality and Safety, Director of Quality, Transplant Administrative
Director, Transplant Operations Director, and Performance Excellence Program
Director meet on a minimum of a quarterly basis. The Transplant Administrative
Director provides a program-specific QAPI update to hospital quality leadership
including any concerns or barriers in which the program needs assistance.
• The Transplant Administrative Director provides annual program-specific QAPI
reports to the Patient Safety and Quality Committee of the UWHCA Board.
• The Vice President of Quality and Safety, Director of Quality, and hospital Chief
Operating Officer are members of the Transplant QAPI Steering Committee and
review program-specific performance and QAPI information during this meeting.
They are also included in the distribution of SRTR program-specific reports
approximately twice per year.
2. Hospital to Transplant:
• The Vice President of Quality and Safety and Director of Quality provide hospital
QAPI information, including current and future activities and priorities, to the
Transplant Administrative Director, Operations Director, and Performance
Excellence Program Director during the Hospital Quality and Transplant
Leadership meetings.
• The Director of Quality provides an update on hospital QAPI initiatives during
each Transplant QAPI Steering Committee meeting.
3. Transplant to Staff:
• Managers are expected to disseminate information from the Transplant QAPI
Steering Committee meeting to their staff.
• Program-specific scorecards are communicated to staff on a monthly basis. This
includes transplant staff and physicians, nursing units, operating room, pharmacy,
and HLA to ensure that staff caring for transplant patient populations have access
to and knowledge of process and outcome measures across the transplant
continuum of care.







POLICY & PROCEDURE
Effective Date: October 2016
Revised Date: October 2016
Title: Transplant Quality Assurance and Process
improvement (QAPI) Policy
Policy Number: 6.0

Page 5 of 5

V. RELATED DOCUMENTS
• Transplant QAPI Plan
• Hospital QAPI Plan
• Policy 3.19 Reporting Unexpected Events
• Policy 5.0 Data Management

VI. COORDINATION
University of Wisconsin Transplant Program

VII. REVIEWED AND APPROVED BY
Administrative Director, Transplant Service Line
Medical Director, Transplant Service Line

VIII. SIGNED BY


________________________________ _________________________________
Jill Ellefson, MBA Dixon Kaufman, MD, PhD
Director, Transplant Service Line Medical Director, Transplant Service Line