ANNA response to JCAHO Field Review: Organ Transplant Center Certification

ANNA Response to JCAHO Field Review: Organ Transplant Center Certification

The following questions are specific to the "Introduction" and "Sections I, II, III, & IV" of the Requirements.

1. Does the introduction prepare the reader for the requirements that will follow?

(X) Yes

(   ) No

Please elaborate on your response:

2. Is the definition of organ transplant center clear?

(X) Yes

(   ) No, if no please elaborate on your response:

The terms are clear, but not consistent with UNOS definitions for Transplant Center and Transplant program which could cause some confusion.

3. Is the definition of organ transplant program clear?

(X) Yes

(   ) No, if no please elaborate on your response:

4. Is it clear to the reader that each organ transplant program would require separate certification and will be evaluated separately?

(X) Yes

(   ) No, if no please elaborate on your response:

I.  Recipient and Living Donor Management (PC)

5. Are there any additional expectations for recipient and living donor management that are not addressed in the proposed requirements?

(   ) Yes

(X) No, if no please elaborate on your response:

6. Are there any expectations for recipient and living donor management that should be deleted from the proposed requirements?

(X) Yes

(   ) No

If yes, please elaborate on your response:

Patient notification: As a UNOS mandate, patients are notified when placed on the list and when they are removed. Yearly notification, even with no change in status, would place a tremendous burden on programs, particularly ones with waiting lists in the thousands.

II. Performance Measurement and Improvement (PI)

7. Are there any additional expectations for performance measurement and improvement in organ transplant programs that are not addressed in the proposed requirements?

(   ) Yes

(X) No

If yes, please elaborate on your response:

8. Are there any expectations for performance measurement and improvement in organ transplant programs that should be deleted from the proposed requirements?

(X) Yes

(   ) No

If yes, please elaborate on your response:

Elements of Performance for PI 3 #2: This may be difficult and time intensive to obtain. Should be the responsibility of the OPOs.

III. Program Management (PM)

9. Are the credentials and qualifications requirements for members of the transplant team reasonable and appropriate?

(X) Yes

(   ) No

If yes, please elaborate on your response:

Transplant Coordinators: 

  • There are other certifications, in addition to ABTC, available that should also meet the certification criteria, and for example ITNS, NNCB, AACN, as well as specialty certifications in related fields. 
  • Having one certified coordinator should be sufficient versus requiring all to be certified. 
  • With the current nursing shortage, it would be extremely difficult to find qualified personnel with limiting to one type of certification and requiring all coordinators to be all certified.
  • This is not consistent with UNOS criteria. 
  • To meet eligibility requirements for any certification, there is typically a 1-2 year a minimum work requirement, in the field; language should be included that recognizes this. 

10. Are there any additional expectations for program management that are not addressed in the proposed requirements?

(X) Yes

(   ) No

If yes, please elaborate on your response:

PM.3 #5: recommend utilization of UNOS standards rather than the transplant center’s Board of Directors to demonstrate transplant physician’s current competence.

11. Are there any expectations for program management that should be deleted from the proposed requirements?

(X) Yes

(   ) No

If yes, please elaborate on your response:

  • PM 7 #5:  Living donations is a very sensitive issue, especially if the donor rescinds their offer and is not willing to tell the potential recipient.  How would this be documented in the potential recipient’s record?  Many donors ask for a ‘medical out’ which would then become a problem, especially if the transplant candidate wants to be evaluated at another center.  Does unsuitability also get documented in the transplant candidate’s chart?  For legal reasons the living donor should be totally separate from the recipients.
  • PM 8.0 Waitlist Management: #3: Should be consistent with UNOS policy, to allow 48 – 72 hours to remove from the waiting list.  Should also be changed from ‘24 hours of death’ to ‘24 hours of notification of death’ as they are often relying on other sources to get that information.

IV. Information Sharing Between Transplant Program and the Organ Procurement Organization (IM)

12. Are there any additional expectations for information sharing between the transplant program and the procurement organization that are not addressed in the proposed requirements?

(   ) Yes

(X) No

If yes, please elaborate on your response:

13.Are there any expectations for information sharing between transplant program and the procurement organization that should be deleted from the proposed requirements?

(   ) Yes

(X) No

If yes, please elaborate on your response:

If you have additional comments, please provide them in the space below and reference the specific requirement number in your comments:

  • The proposed JCAHO requirements are comprehensive and the guidelines reflect the standards to which a transplant program aspires. 
  • They should be consistent with UNOS and CMS requirements. 
  • Implementation of, and meeting, the criteria set for Waitlist Management will be difficult to meet day-to-day.