Case Studies
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Interest(s): Advanced Practice Professionals, Checklists & Forms, Cultural Perspectives, Diversity, Equity and Inclusion, Electronic Medical Records (EMR), Emerging Technology, Ethics, Finance, Growth in Transplantation, Hospital Donation Process & Education, HR & Staffing, Immunosuppression / Transplant Pharmacology, Innovation, Job Descriptions / Competencies, Legal and Regulatory, Living Donation / Paired Donation, Patient Education / Healthcare Literacy, Patient Safety, , Quality Assurance and Performance Improvement (QAPI), Transplant Financial Coordinator, Transplant Nutrition, , Waitlist Management
Organ(s): Heart, Intestine, Islet Cells, Kidney, Liver, Lung, Pancreas, Small Bowel, Vascularized Composite Allograft (VCA)
Patient Group(s): Adult
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From Compliance to Competency: Elevating Transplant Quality Through Structured Frameworks and Standardized Roles
Celeste
Braly
, UW Health Transplant Center
The Challenge
Across the U.S., transplant centers vary significantly in the structure, staffing, and focus of their quality programs. While regulatory compliance forms the foundation, few programs operate from a standardized framework that integrates improvement science, role-based competencies, and culture-building. Additionally, national variation in job titles, responsibilities, and onboarding processes makes it challenging to benchmark or sustain quality work across transplant domains.
Three years ago, our transplant center identified an opportunity to further strengthen and advance its quality and patient safety program. Foundational structures were already in place—including routine QAPI meetings, dedicated team members, and reliable data abstraction processes. Building on this solid base, we sought to evolve the program into a fully integrated, data-informed, and improvement-driven model. We recognized the potential to expand the scope of quality work beyond compliance, enhance the use of analytics, and formalize onboarding, standard work, and professional development to support long-term sustainability and excellence.
To address this, we launched a strategic redesign of the entire program. Our work was guided by two nationally recognized frameworks: the NAHQ Healthcare Quality Competency Framework, which allowed us to structure quality roles around eight defined domains of practice, and the IHI Framework for Safe, Reliable, and Effective Care, which helped us embed the principles of system learning, psychological safety, and culture of improvement. Our goal was to create a model where quality expertise is clearly defined, consistently applied, and aligned with both operational and clinical excellence.
We sought to build a program that fostered engagement, empowered staff with quality science skills, and aligned deeply with our transplant center’s mission and complexity. By developing a standardized approach to role design, analytic integration, and structured improvement, we aimed to build not just a functional QAPI program, but a learning health system grounded in competency, culture, and strategy.
This abstract outlines the foundational assessment, redesign process, and outcomes of that transformation. The resulting model has implications for national transplant practice and offers a replicable, scalable approach to strengthening transplant quality infrastructure.
The Approach
The transformation of our transplant quality program began with a comprehensive baseline assessment to understand both structural and cultural opportunities. This included a formal SWOT analysis to identify existing strengths and opportunities across regulatory compliance, data workflows, team capabilities, and improvement activities. Concurrently, we reviewed internal metrics such as:
Number of QAPI-related action items and improvement initiatives
Attendance and engagement trends in QAPI meetings
Volume and scope of safety event reviews tied to follow-up actions
To align our efforts with evidence-based frameworks, each transplant program (heart, kidney, liver, living donor, lung, and pancreas) completed a structured assessment using the IHI Framework for Safe, Reliable, and Effective Care Diagnostic Tool. Each domain of the framework was evaluated using IHI’s maturity scale—“Just Beginning,” “Making Progress,” “Significant Impact,” or “Exemplary.” Most areas across programs fell into the early stages of development, reinforcing our vision for an intentionally designed learning system focused on psychological safety, leadership alignment, and reliability science.
We also conducted a review of all job descriptions for quality team members to assess alignment with the NAHQ Healthcare Quality Competency Framework. This revealed that while the team was deeply committed, their roles emphasized data abstraction and regulatory response more than facilitation, data analytics, or improvement leadership. To ensure stakeholder alignment, we also engaged transplant program leaders through interviews and polling to understand their expectations and needs from the quality team. These conversations identified a key opportunity: to create clarity around what quality is, how it supports transplant outcomes, and how to embed it within daily operations.
Using these inputs, we designed a new structure anchored in two quality “pods” (Abdominal and Thoracic), aligned to all organ programs and mapped directly to NAHQ’s eight competency domains. We developed new reporting structures and workflows to support this structure. We realigned responsibilities and refocused the scope of existing roles to better reflect NAHQ’s eight competency domains, without changing job titles or formal descriptions. RN Data Analysts received targeted training in data analysis, facilitation, improvement methods, and safety event investigation. One RN Data Analyst embarked on EPIC certification to support deeper integration with enterprise analytics. Standard work documents were developed for all roles and workflows to ensure consistency, continuity, and scalability.
This structured, framework-based approach became the foundation for an integrated, competency-aligned, and culturally grounded transplant quality program.
The Results
One year after implementing our redesigned transplant quality program, we have observed measurable impact across structure, engagement, analytic capability, and improvement outcomes.
A pod-based model was implemented, organizing the quality team into two multidisciplinary units—Abdominal and Thoracic—aligned with respective transplant programs, including pediatrics and living donation. Each pod includes RN Data Analysts (three in Abdominal, two in Thoracic) assigned to specific organ programs, a Data Coordinator, and a Regulatory and Quality Improvement Specialist. A dedicated Business Data Analyst supports both pods, with leadership provided by the Program Director for Transplant Performance Excellence and ultimate oversight from the Director of Quality and Compliance. Responsibilities across all roles were aligned to the eight NAHQ competency domains, creating shared expectations and a consistent language for quality practice.
Comprehensive standard work was developed for all roles and workflows, improving continuity, onboarding, and operational independence. RN Data Analysts completed structured education in improvement science, including A3 thinking, data analysis, and the application of quality methodologies. One RN Data Analyst pursued and achieved advanced EPIC certification (Cogito, Clarity, Caboodle), further enabling analytic integration with enterprise systems.
As a result of this transformation:
All RN Data Analysts completed structured education in improvement science, including A3 thinking, data interpretation, and quality methodologies.
A robust suite of dashboards and analytic tools was developed, supported by the EPIC-certified RN Data Analyst and Business Data Analyst aligned with enterprise analytics.
A3 problem solving, PDCA cycles, fishbone analyses, etc., became standard practice.
More than 20 quality improvement initiatives have been launched or completed across programs, most involving interdisciplinary teams.
Data requests increased in both volume and complexity, with faster turnaround and clearer reporting.
Patient safety events are now routinely linked to structured action plans with documented follow-through.
Physician and program leader engagement has increased, with greater participation in meetings, aligned priorities, and proactive collaboration.
Internal perception data reflect greater ownership and active involvement in quality work among staff.
This integrated, framework-based model has elevated our quality infrastructure into a high-functioning, sustainable system that supports transplant excellence through data, collaboration, and continuous learning.
Insights & Lessons Learned
The transformation of our transplant quality program addresses a critical gap seen across transplant centers nationwide: the absence of a standardized, competency-based model for structuring transplant quality programs. While regulatory compliance provides an essential foundation, many programs lack clearly defined roles, professional development pathways, and a framework that supports sustained, system-level improvement.
Our approach intentionally integrated two nationally recognized frameworks—the NAHQ Healthcare Quality Competency Framework and the IHI Framework for Safe, Reliable, and Effective Care—to guide both the structural and cultural redesign of our program. By aligning responsibilities to the eight NAHQ competency domains and embedding principles of psychological safety, leadership alignment, and system learning from the IHI model, we created a dual-framework structure capable of sustaining long-term performance and engagement.
One of the most valuable insights from this work was the recognition that quality expertise must be defined, cultivated, and integrated into daily operations. Prior to this transformation, quality roles primarily supported regulatory and reporting functions. By shifting focus toward proactive analysis, facilitation, and improvement leadership, we empowered team members to operate with increased confidence, visibility, and strategic relevance.
This model has strengthened cross-functional collaboration, accelerated improvement timelines, and created clearer expectations for how quality is delivered and measured across all transplant domains. The creation of standard work, paired with a strong professional development foundation, ensures consistency and scalability, even in the context of turnover or programmatic growth.
We believe this framework-based approach offers a replicable model for transplant centers nationwide seeking to evolve their quality infrastructure from reactive compliance to strategic, sustainable excellence. As the national landscape continues to emphasize transparency, performance, safety, and value, transplant programs must adopt structures that support consistency, data-driven decision-making, and a culture of continuous learning.
By defining what quality looks like in practice—through aligned roles, integrated systems, and empowered professionals—this model demonstrates that high-functioning transplant quality programs are not only achievable but essential to advancing the field.