Medical Center Wide Activities
The Transplantation Program participates in pertinent institution-wide performance and quality of care activities, including the following.
- Infection Control Program surveillance for surgical site infections, blood stream infections, urinary tract infections, and nosocomial pneumonias. Infection rates are established; pathogens are profiled; and data is risk stratified, externally benchmarked with National Health Safety Network system data, and reviewed by the transplant programs.
- Biannually and as needed, physician profile data is collected and aggregated by the Department of Quality Management from a broad range of sources. Physician-specific performance profiles are created, including information on complaints and compliments, medication use, peer review attributions, inpatient utilization, complication and mortality rates, and medical record delinquencies. This information is used for re-credentialing and, as needed, to generate specific follow-up actions.
- The Medical Director’s Office may conduct periodic ad hoc reviews to assess program performance or issues. Information obtained from such reviews may address coordination of care, quality of diagnostic evaluations and therapeutic management, potentially attributable complications, and documentation issues.