Kidney Transplant

2013

People

Item / Responsible / Timeline / Status / Date Completed
1.1 / Certify at least one coordinator as CCTC. / 4Q2013
1.2 / Maintain a fully functioning nursing staff in all areas. Maintain turnover rate of 10% or less for RN’s. / 4Q2013
1.3 / Evaluate effectiveness and role of Transplant Assistant position. / 1Q2013
1.4 / Add second transplant nephrologist. / 2Q2013
1.5 / Evaluate effectiveness of new staffing plan resulting from Staffing Analysis. / 2Q2013
1.6

Customer Satisfaction

Item / Responsible / Timeline / Status / Date Completed
2.1 / Collaborate with marketing staff to develop specific kidney transplant related marketing within the integrated transplant marketing strategy. / 4Q2013
2.2 / Review/revise web pages. / 2Q2013
2.3 / Evaluate patient/family/nursing staff response to IP evaluations. / 1Q2013
2.4 / Evaluate patient response and CV compliance after implementation of timed appointments. / 2Q2013
2.5 / Evaluate and revise/refine as necessary the role of the IDA using Spiritual Wellness staff.
  • Program management
  • Spiritual Wellness staff
  • Patients/families
/ 2Q2013
2.6
2.7

Metrics are underlined.

Growth and Development

Item / Responsible / Timeline / Status / Date Completed
3.1 / Evaluate and assign referring physicians and potential referring physicians into four categories and develop strategy for corresponding with each tier:
  • Tier 1 – those who refer to us all the time
  • Tier 2 – those who refer to us and to others
  • Tier 3 – those who don’t like us
  • Tier 4 – those who don’t know us
/ 2Q2013
3.2 / Identify at least one new nephrology group and get at least three referrals from that group. / 4Q2013
3.3 / Implement pancreas program. / 3Q2013
3.4 / Implement paired donation program. / 2Q2013
3.5 / Obtain three commercial insurance contracts. / 4Q2013
3.6 / Increase outreach to dialysis centers. / 4Q2013
3.7
3.8
3.9

Metrics are underlined.

Clinical and Administrative Quality

Item / Responsible / Timeline / Status / Date Completed
4.1 / Nominate one qualified person for each open UNOS Region 8 position. / 3Q2013
4.2 / Update Access database to contain necessary data fields. / 1Q2013
4.3 / Achieve 100% on UNOS data requirements:
  • ABO verification at time of transplant
  • Removal of patient from UNet within 24 hours of transplant
/ 4Q2013
4.4 / Produce at least one program abstract or publication:
  • Article submitted
  • Presentation at regional or national meeting
  • Abstract submitted
/ 4Q2013
4.5 / Receive release from CMS for completion of SIA. / 1Q2013
4.6 / Complete policy revisions and guideline re-writes as needed.
  • Get policies on-line.
/ 1Q2013
4.7 / Complete at least one PI project. / 4Q2013
4.8 / Continue to refine quality plan:
  • Meeting content
  • PI projects
  • Audits

4.9 / Evaluate results with use of and refine as needed the “At Risk” criteria for post-transplant patients. / 3Q2013

Metrics are underlined.

Financial

Item / Responsible / Timeline / Status / Date Completed
5.1 / Meet budget. / 4Q2013
5.2 / Achieve Center of Excellence with at least one payor. / 3Q2013
5.3 / Review clinic charges with Lynn Vaughn to assure appropriate capture and make additions/deletions as needed. / 2Q2013
5.4
5.5
5.6

Metrics are underlined.