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 Documentation
Number of New Patient Admissions this month
Number of patients REFERRED to the transplant center for evaluation this month
Number of NEW patients added to the transplant waitlist this month
Root Cause Analysis
What is the top barrier you believe prevents patients from being placed on the transplant waitlist at your facility?(this will be the focus of your monthly PDSA cycles)
Identify which of the 6 Steps in the Transplant Waitlist Process you are addressing in the identified barrier?
Monthly PDSA Cycle Documentation
Describe your monthly plan to improve the identified barrier (include details such as Who, What, When)?
Describe the intervention(s) you did this reporting month to improve patients' transplant waitlist status and what did you observe?'
Did you achieve the plan’s goal with this reporting month’s intervention(s)?
Take a moment to think about your intervention(s) this reporting month. What did you learn about the effectiveness of the intervention(s)?
What Barrier(s) (if any) did you discover when implementing the intervention(s) this reporting month? (Enter NA if none)
What are you going to do for your PDSA cycle NEXT month?
On a scale from 1-5 with 1 needing improvement & 5 being excellent; rank your facility and transplant communication process.
Describe your current method of communication between your facility and your transplant plant center; what is the follow up process for referrals?
Describe any communication barriers or challenges that exist with your current communication with transplant programs.
Next Step: Patient Engagement
Describe how you are incorporating patient engagement into your project plan for this month.
Do you currently have a patient support group at your facility?
Number of new patients added to the waitlist this month
Copy and paste from your QAPI notes what you entered and discussed regarding the Network Project to increase the number of transplant waitlisted patients in your facility this month?
Next Step: Verify and Submit
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