Paul Gaglio, MD
The Montefiore Medical Center Heart Transplant & Assist Device Program, Kidney Transplant Program, and Liver Transplant Program participate extensively in quality assurance and performance improvement activities. The programs' endeavors are defined within three broad spheres of quality improvement activity.
Organ Transplant Performance Improvement Plan
- 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.
- 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.
- 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.
- 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.
To ensure consistent, impartial and professional evaluations of care, transplantation services will be subject to peer review in all cases that meet the following criteria:
- Mortality (elective admission, within 48 hrs of OR, unexpected)
- Delay in diagnosis
- Readmission within 3 days
- Unplanned return to the operating room
- Procedural events (e.g., surgical injury, anesthesia injury, pneumothorax related to intravascular catheters; unintentionally retained foreign bodies)
- Variations in standards of care as identified by regulatory agencies (e.g., New York State Department of Health Patient Occurrence Reporting and Tracking System)
- Variations in standards of care defined by transplant services
All cases for peer review are prepared in conjunction with a Quality Management Coordinator. Surgical care is reviewed by the appropriate departmental peer review committee, and will include peers with experience with these procedures. The primary surgical (or medical) provider whose care is being reviewed is not involved in the review. If non-surgical care is questioned, cases are referred to other Peer Review Committees (Cardiology, Medicine, Nursing, etc.) Extramural expertise may be sought to review cases for which internal peers are limited.
Attributions and findings made as a result of this process will be summarized and reported to the Peer Review Board, and incorporated into the recredentialing processes. The Peer Review Board reports to the Montefiore Quality Council per Medical Center Policy. Based upon the above reviews, the departmental committee chairperson may determine that some cases require more focused reviews. Each program may also elect to further discuss peer review cases in interdisciplinary morbidity and mortality teaching conferences.
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.