The Alliance

•   Name
•   Date of Listing
•   Wait List Status
•   MRN
•   Age
•   Race
•   Gender

•   MRN

•   Name
•   MRN

•   Name
•   MRN

•   Decision Date
•   Decision Reason

•   Name
•   DOT
•   MRN
•   Age

•   Race
•   Gender
•   Address
•   Country of primary residence
•   Date of Death / Graft Failure

•   Name
•   MRN
•   Organ donated
•   Date of donation

•   Unit
•   Floor

  Schedule for all multidisciplinary team meetings *including rounding

•   Attendance and roles of the team members
•   Leadership and collaboration within the team
•   Communication among team members
•   Involvement of recipient/family in care decisions
•   Documentation and evidence of individualized implementation and evaluation of patient’s plan of care to ensure they are meeting their goals

  Schedule of Selection Committee meetings

•   Attendance and leadership of the meeting
•   Team participation in patient discussion
•   Selection criteria used
•   Process for making determinations
•   Outcome of meetings
•   Results shared with patient/family
•   Review of prior minutes for consistency

  Schedule of all QAPI meetings

•   Team member attendance
•   QAPI leadership identification
•   Issues and concerns identified
•   Improvement plans and follow-up
•   Action items and results documented

  Organizational chart

  Incorporates how the transplant center fits into overall hospital organization

  Incorporates transplant center into hospital organization. Include, but not limited to:

•   HLA services
•   Living donor – NKR, APD

•   Agenda
•   Dates
•   Evidence of attendance

  Adverse Events for the past 24 months (New extended time frame)

  Adverse Event/ Occurrence Policy

  Quality Assessment and Performance Improvement (QAPI) Plan

  Hospital QAPI Plan

  QAPI reports, records, minutes

  Patient Selection Criteria for transplant and living  donors

  ABO Verification Policy Transplant Recipients & Living Donors

  Include associated blank forms

  Waiting list management policy

  Including patient notification

  Psychosocial Evaluation Policy for transplant candidates and living donors (new policy requirement)

  Update policies to include the following:

•   The length of time in which the psychosocial evaluation is deemed to be current and/or frequency of re-evaluation to determine continued appropriateness;
•   The type of qualified professional healthcare personnel (MSW, LCSW, psychiatrist or psychologist) who may complete these evaluations;
•   The follow-up and referral procedures if a transplant candidate requires such activities; and

  The method of communicating the psychosocial evaluation findings into the selection process.

  Patient Management Policies for transplant and Discharge

•   Transplant programs should define the structure of their evaluation and transplant processes
•   Patient management policies for the discharge phase of transplant should have mechanisms in place to identify, assess, and meet the medical and psychosocial needs of the patient to ensure they have the resources necessary to care for their transplant.
•   These patients will require discharge planning at an early stage of their hospitalization to ensure their discharge needs are identified and addressed prior to actual discharge.

  Living Donor Management for Pre-donation, donation and discharge phases

•   Transplant programs that provide living donor transplant services must develop and implement living donor policies that direct the care and management of donors through their evaluation, donation, and discharge after donation.
•   The evaluation policies must ensure it incorporates at a minimum, all potential donors that have chosen to undergo all or any portion of the transplant program’s evaluation process.
•   Transplant programs should ensure its discharge policies for living donors are based on the hospital policies for discharge planning.

  Policy needs to be updated to include the following:

•   Who is responsible for discussing the informed consent process with the potential donor;
•   Where the discussions concerning the informed consent process are documented in the medical record;
•   The methods used by the program to ensure and document the potential donor’s understanding of the information being delivered; and
•   When the discussion(s) will take place, if the information is provided at different points of the donation process.

•   The transplant program’s policies must address communication methods to inform patients of situations or events that could impact their ability to receive a transplant.
•   If the event is related to an emergency situation, which may or may not require transfer of patients to another hospital, the transplant program is expected to notify patients on the waiting list of the emergency plan in accordance with the program’s emergency preparedness protocol in place.

  Patient Education: all material used pre and post-transplant and pre and post living donation

•   Include education that explains selection criteria.

  A request for nutritional and/or social services can also be made by the patient, family member(s)/caretakers, and/or the patient’s multidisciplinary team.

  Have written evidence of a contract or agreement with the living donor transplant program(s). This may be a specific contract or agreement between two hospitals or programs, or it may include participation in a transplant registry for paired donation of living donors and recipients.

  Have a copy of the Medicare-approval letter for the living donor transplant program with which it has a contract or agreement, or have documented evidence that the CMS website listed below was reviewed prior to accepting the living donor organ to ensure that the program was a Medicare-approved program.

  Donor record information requirements:

•   There is a complete medical and psychosocial evaluation in the medical record completed by the relevant professionals of a multidisciplinary team which has determined that the individual is a suitable living donor.
•   An Independent Living Donor Advocate (ILDA) has met and worked with the potential living donor and has been included in the discussions of the potential donor’s suitability.
•   There is a fully documented informed consent process in the living donor’s medical record that meets the minimum Medicare requirements.

  As part of the Quality Assessment and Performance Improvement (QAPI) requirement, ensure that there is a feedback system between the recipient and donor hospital to address any adverse events that occur in the donor or the recipient for a specific donation or transplant.