Project Guidelines

Transplant is one of several renal replacement therapy option that offers the opportunity for better clinical outcomes with reduced mortality and morbidity and improvement of life. CMS Definition of a Transplant Referral: “any first-time referral for a patient (i.e., the patient has not already been referred or been placed on a transplant waitlist), and for which either a dialysis facility or transplant center provides an indication that the patient has been referred. Patients who have had transplant failures are considered as restarting the referral process anew, and would be eligible for “first-time” referrals.”

AIM: <25% of the target population must demonstrate the desired outcome for the selected project area

Baseline: Period of six months (April - September 2016) and an intervention period of with eight months (February 2017 - September 2017)

Goal and Timeline: To include a five percent (5%) increase in the rate of transplant referrals for eligible patients, as well as a one percent (1%) reduction in the identified disparity group (gender) by September 2017

Project Interventions

• Utilize Network-Developed Resource Toolkit
• Develop dedicated Transplant “Education Station”
• Submit Reporting Requirements (RCA/CAP, Monthly Collection Tool, Use Forecasting Tool)
• Participate in Network Site Visits
• Establish Peer Mentor Program
• Participate in Network’s Transplant Advisory Committee

Project Resources

Transplant Resource Toolkit Page
Peer Mentorship Training Program Page

Project Timelines

Baseline Measure Period: April – September 2016
Ongoing Measurement: (Monthly) February – September 2017

January 2017
Facility Notification: Including project overview, project RCA survey, and monthly timeline
Identify Facility Lead & Coordinator: Facilities identify project lead and designated transplant coordinator.
QIA Kickoff Webinar: Launch QIA activities, provide an overview of 2017 interventions and a demonstration of the project tools Slides


Reporting: Completed 5-Whys RCA tool by February 15, 2017

March – September 2017:

Facilities will:
Report Monthly (VIA FAX ONLY): Transplant Referral Collection Tool listing patients newly referred for transplant. Form to be faxed no later than the last day of each month.
Review Network Resources: Provide ongoing feedback for improvements needed.
Collect patient success stories: Submit Patient Stories to the Network for publication.
Monitor Progress: Work with Network monthly on 1:1 monitoring of progress towards goals using disparity goal forecasting tool.
Establish a dedicated Transplant Education Station using Network resource toolkit
Host Education Event: Coordinate with Network Transplant Navigator, and a Patient Peer Mentor to host at least one (1) educational event using Education Station
Participate in Transplant Advisory Committee virtual meetings

The Network will:
Provide Materials: facilities will be sent transplant educational poster and resource toolkit binder with sample patient packets, and printed materials/tools for patients and staff education
Assess facility goals and progress: Network Staff will mentor facilities 1:1 monthly to assess progress and evaluate benchmarks
Change interventions for facilities falling below identified progress goals
Make Site Visits: Network Staff will visit facilities to educate and review the project with staff Perform face-to-face site visits where needed (May through July)
Provide Bi-Monthly Education Resources: Network staff will share educational resources, articles, or webinars on a bi-monthly basis (April, June, August, October)
Host Virtual Meetings: Transplant Advisory Committee bi-monthly meetings (March, May, July, September)

Patient and Healthcare Team

For more information:

Michelle Lewis
Quality Improvement Data Coordinator