Increasing Transplant Waitlist
Facility Contact First Name:
Facility Contact Last Name:
Facility Contact Email:
WARNING: DO NOT ENTER PHI / PII ON THIS FORM.
No PHI / PII in the following fields.
Examples of PHI include patient name or initials, birthdate, SSN, etc.
Next Step: Root Cause Analysis and PDSA Cycle
Root Cause Analysis
Background: Network facilities are required to work with CMS toward achieving the 2019 goals of improving transplant coordination and increasing the number of patients on the transplant waitlist. Use the facility self-assessment tools provided in the December project notification mailing to assist you in doing a root cause analysis (RCA) of barriers and processes impacting the wait-listing process with the aim of maintaining or improving your process using PDSA cycles.
1. Choose ONLY ONE of the facility activities on the self-assessment to which you responded "No" or "Not Always" to prioritize for improvement and complete monthly reporting.
2. When you resolve it to your satisfaction, you can move to the next area you would like to address and choose it for reporting.
3. The barrier to address can apply to one or multiple patient, facility or staff situations.
Barrier: If select "Patient Refused", specify reason for refused
Barrier: If select "Other", specify RCA
Which of the six steps does the barrier you identified
Monthly PDSA Cycle Documentation
Describe your monthly plan to improve the identified barrier (include details such as Who, What, When)?
Select from the drop down the one intervention you used this month to address your identified barrier. For your first reporting month, select the one you plan to use.
If "Other" is selected; describe the intervention you did this reporting month to improve patients' transplant waitlist status. What did you observe?'
Did you achieve the plan’s goal with this reporting month’s intervention?
Take a moment to think about the intervention this reporting month. What did you learn about the effectiveness of the intervention?
What Barrier(s) (if any) did you discover when implementing the intervention this reporting month? (Enter NA if none)
What are you going to do for your PDSA cycle NEXT month?
Document your adjusted plan HERE for NEXT month:
Document your new plan HERE for NEXT month:
Next Step: Metrics
How many of your patients are on the transplant waitlist (active and inactive)?
How many facility patients attended their initial transplant evaluation this reporting month?
How many patients were added to a transplant waitlist this collection month?
Do you have processes established for sustaining the transplant waitlist rate in your facility?
What action item have you put in place for sustainability?
What action item have you put in place for sustainability? If you selected "other" than specify
Next Step: Verify and Submit
Verify you are not a robot and submit your data using the Submit button
at bottom of the form