Einstein/Montefiore Department of Medicine

Performance Improvement Plan

Organ Transplant Performance Improvement Plan

  1. Transplantation Protocols

    Transplantation program-defined policies and procedures govern overall operation, including patient selection, wait list management, care coordination, pre-transplant, peri-operative and postoperative management. Transplantation teams meet regularly to review patient care issues, identify areas of improvement, and revise policies and procedures accordingly.
  2. Performance and Process Improvement Data

    Program coordinators, data managers, administrative and nursing personnel collect data on the care of transplant patients encompassing key aspects of patient selection, wait list management, care coordination, pre-transplant, peri-operative and post-operative management.

    Evaluative performance measures include:

    • Patient and donor selection (medical history, status, appropriateness of selection)
    • Pre-transplant care (timeliness of evaluation, wait list management)
    • Intra-operative management (organ ischemic times, blood product utilization)
    • Post-operative care (complication, re-operation, and infection rates)
    • Overall measures (volume, length of stay, mortality rates, patient satisfaction, readmission rates)
    • Measures required by external agencies (including Medicare and Medicaid, Joint Commission, NYS Department of Health, and numerous transplant societies)

    Transplant program leaders further define measures, using externally standardized and cross-program definitions.

  3. Team Structure and Accountability

    A designated physician oversees performance improvement activities, working closely with the transplant program, departmental, support (Quality Management and the Network Performance Group), and medical center personnel and leadership to procure data and implement improvement activities.

    Multidisciplinary leadership and transplant program personnel (physicians, coordinators, nurses, administrators) execute the performance improvement, with support from Quality Management and Network Performance Group staff.

    Regular reviews of internal results and external reports are used to monitor changes in performance and suggest steps for improvement.
  4. Organ Transplant Performance Improvement Committee

    An interdisciplinary Organ Transplant Performance Improvement Committee meets at least quarterly to review program performance and quality improvement activities, seeking to continuously improve transplant services, facilitate communication, and identify opportunities for alignment and standardization among transplant programs.

    The Committee reviews program policies and procedures, changes in external/regulatory requirements, data, information technology applications and data repositories, and annual reports.

Contact Us

Department of Medicine
Albert Einstein College of Medicine
Jack and Pearl Resnick Campus
Belfer Building - Room 1008
1300 Morris Park Avenue
Bronx, NY 10461 (directions)

Physicians and Patients:
866-MED-TALK (866-633-8255)

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Administrative Questions:
Fax: 718-430-8659

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