Staff
Where would you report a patient experience complaint?
What is...
Through the Event Reporting System.
How do staff access policies for our program?
Through PolicyStat.
By our center's policies, what is a "qualified professional" in the context of verifying ABO prior to wait-listing a patient?
What is...
A team member that has completed the "waitlist management" and "ABO puzzling it out" courses and has received training as appropriate to their role.
When is the informed consent process for evaluation of potential transplant recipients initiated?
What is...
Prior to the evaluation.
How many dogs has Cara fostered (total)?
What is...
73!
What is an adverse event as defined by CMS?
An untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.
Describe how our center communicates with our dialysis centers.
What is...
X-120 Dialysis centers are notified about wait list changes; laboratory results; and changes in medical condition. Letters must be sent out/dialysis centers notified within 10 business days of the committee decision.
How does the Transplant QAPI program interact with the hospital level quality program?
What is...
Bidirectional information and communication flows to and from DSMCUT Joint Practice & Performance Excellence Council, the Quality and Patient Safety Committee of the Board for Ascension Texas, and the Transplant QAPI Committee
Prior to an evaluation, what must patients be informed of about the evaluation process?
What is...
X-151
What the potential recipient and transplant program responsibilities will be
All possible decisions regarding waitlisting and transplantation that could be reached as a result of the evaluations
What factors could result in their removal from the waiting list
How many plants do we have in the clinic?
What is...
17
What areas of multidisciplinary care are assessed for discharge planning of a patient?
What is...
X-091
1. Medical
2. Psychosocial
3. Financial
Briefly describe the ILDA grievance policy.
(acceptable responses include a brief overview of the following)
What is...
Any team member can file a grievance if they are concerned about the integrity of the living donor's consent. Grievances are first shared with the ILDA. If they feel the matter was not resolved, they can share the grievance with the following entities:
Describe a quality metric relevant to your role.
What is...(includes, not limited to)
Transplant Coordinators: Data submission
Pharmacy: Evidence of multidisciplinary care
Social work: Evidence of psychosocial assessment and discharge planning
Clinic RN: "Time-To" data
Nephrology: Evidence of multidisciplinary care, selection committee notes
Surgeon: Graft and patient survival data, surgical site infection rate, unplanned take backs to the OR
Dietitian: Evidence of multidisciplinary care
ILDA: Pre-eval interview and psychosocial assessment
Financial Analyst: Evidence of multidisciplinary care
What does CMS define informed consent process as?
What is...
X-150 Informed consent is a process that requires a health care provider to disclose all available information to a potential recipient who makes the voluntary choice to accept or refuse treatment.
What does HIM stand for? (wrong answers only)
Health Information Management is the correct answer, but I am looking for the funniest wrong answer.
Why do we have an Independent Living Donor Advocate?
What is...
X-124
To ensure that the donor's decision is informed and free from coercion.
Describe how policies are created and reviewed within our transplant center.
What is...
1. Initiation
2. Development and Preliminary Approval
3. Review and Approval
4. Publication and Management
What is the difference between an outcome and process measure? Provide two example metrics of each that our center tracks.
What is...
Process measures relate to the evidence-based care administered to a patient; outcome measures evaluate the effect of that care on the patient’s health.
Process Measure Examples: Evidence of documentation, Two ABOs present prior to date of listing, date of case selection committee meeting documented
Outcome Measure Examples: Death on waitlist, unplanned return to OR, total ischemic time
SRTR data must be included (when available) in our informed consent process. What must patients need to be told prior to undergoing an evaluation about SRTR?
What is...
The location of the SRTR website, how the website may be used by the potential recipient to review the transplant data pertaining to the program's performance, and a contact at the transplant program whom they may contact for any additional questions or assistance with use of the website. (X-155)
As a team, write the birthday month for each member of the transplant clinic team.
What is...
January - Travis
February - Cara
March - Ernest, Brian
April - Nicole, Beth
May - Gloria, Katelyn, Michelle
June - None!
July - Melissa
August - Jayna, Jesica, Joyce
September - None!
October - Joel, Jane
November - Rachael
December - Katie, Erin, Meredith
What sections of a patients medical record will CMS surveyors focus on?
What is...
TASK 4
1. Evaluations: psychosocial and medical
2. Patient selection criteria
3. Informed consent documentation
4. Blood type, ABO and UNOS ID verification
5. Operative reports
6. Progress notes for patient care, staff activities, informed consent discussions, etc;
7. Multidisciplinary care plan and patient teaching tools for involvement of all key personnel
8. Discharge planning; and
9. Follow-up (outpatient) cart or section of the record.
Describe the waitlist policy
What is...
Major talking points:
1. We have a waitlist policy and a waitlist communication policy, found in PolicyStat
2. Patients have 90 days from listing to complete pending items. If items are not completed, they are delisted (per policy)
3. Patients will be monitored to determine if updated testing, evaluation, or consult is necessary.
4. We will notify and educate patients and dialysis centers (if applicable) about their listing or change in status
What are the five elements of QAPI according to CMS?
What is...
1. Design and Scope
2. Governance and Leadership
3. Feedback, Data Systems, and Monitoring
4. Performance Improvement Projects (PIPs)
5. Systemic Analysis and Systemic Action
What are at least 5 elements that must be included in an informed consent for evaluation for RECIPIENTS?
What is...
1. X-151 Information about the evaluation process PRIOR TO IT'S INITIATION
2. X-152 The Surgical Procedure
3. X-153 Alternative Treatments
4. X-154 Potential medical or psychosocial risks
5. X-155 National and transplant program-specific outcomes from the most recent SRTR program-specific report.
6. X-156 Organ donor risk factors
7. X-157 right to refuse transplantation
8. X-158 The fact that if his or her transplant is not provided in a Medicare-approved transplant program it could affect the transplant recipient's ability to have his or her immuno-suppressive drugs paid for under Medicare Part B
Draw Mr. Pancreas