FQAPI OUI 2015 Janet Drelicharz RN, MSN
CMS Transpla plant nt Quality ity Webinar ar Series Focused Quality Assessment & Performance Improvement FQAPI March 2015 2
FQAPI API – CMS Transpl plant ant Quality ity Webinar r Series What’s on the Radar ◦ Current Important Issues in the World of Transplantation ◦ Data Rich Information Poor ~ DRIP Using information to make improvements A means to track improvements is required To track improvements, need to identify the issue(s) Baseline Changes Analysis 3
FQAP QAPI I – CMS MS Tran ansplan plant t Quality uality Webin inar ar Series ies Curren rrent t Aud udit it Key Issue ues Immunosuppression Selection Criteria Graft Survival Cardiac Events Infections Technical Competency of Harvest Team Prophylaxis Related to Immunosuppression Serology Testing Delayed Graft Function Patient Education Follow Up Visits Re-Admissions Waitlist Management Nutrition Bleeding – Quality of Organ Team Structure and Training 4
OTTR Management of the Key Issues Immunosuppression Selection Criteria Graft Survival Cardiac Events Infections Prophylaxis Related to Immunosuppression Delayed Graft Function Patient Education Follow Up Visits Re-Admissions Waitlist Management Nutrition Bleeding – Quality of Organ 5
Immunos osuppr uppres essio sion & Prophyla ylaxi xis 6
Immunos osuppr uppres essio sion & Prophyla ylaxi xis 7
Immunos osuppr uppres essio sion & Prophyla ylaxi xis 8
Se Sele lectio ion n Crit iteria ia 9
Gr Graft Su Surviv ival al 10
Cardia iac Events ts 11
Infe fections ions 12
Dela layed yed Gr Graft Func nction ion 13
Patie ient nt Education tion 14
Patie ient nt Education tion 15
Foll llow Up Up Vi Visit its 16
Foll llow Up Up Vi Visit its 17
Re Re-adm dmis issio sions ns 18
Wait itli list t Manag ageme ement nt 19
Nutrit ition ion 20
Ble leedi ding ng 21
Quali lity ty of Orga gan 22
Quali lity ty of Orga gan 23
Actions ADT Encounters Evaluation Phase Medications Problem Lists Text Documents Transplant Record 24
“Poor transplant outcome utcomes can an indicate dicate a defic icien iency cy in transp nspla lant q uality management.” Doc ocume umenti ting Trackin acking Analy nalysis sis Ackno knowled ledgem gemen ent t of f defic ficit it and nd interven erventio ion Mon onit itor for susta tain ined ed chan hange ge 25
Con onsider sideration ations: Dupli plica cate te Ent ntry EMR Excel cel Spreadshe eadsheets ets Manu nual l Time me Cons onsum umptio ption Reli liabil ility ity Personn onnel el Cos ost Audit dit Deficien iciencies ies System ems s Improvem rovemen ent t Agreeme eements CMS S Probation bation 26
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