In December 2014, the Organ Procurement and Transplantation Network (OPTN) implemented a new Kidney Allocation System (KAS), expanding the dichotomy of extended and standard criteria donors to include a spectrum of 10 specific donor characteristics, forming the Kidney Donor Profile Index (KDPI). Along the spectrum, kidneys with a high-KDPI (> 85%) were perceived as suboptimal and at higher probability for discard.1 Policy requires additional consent for a candidate to be offered these kidneys while on the waiting list. Although moderate-to-high KDPI (50-100%) kidneys have shown a survival benefit as compared to waiting for the next lower-KDPI graft, discard rates in the United States have hovered around 20 percent.2 Furthermore, there is a perception across the transplant community that use of suboptimal kidneys would lead to higher patient and graft loss resulting in flagging by the OPTN MPSC (Membership and Professional Standards Committee).3,4
New approaches to target kidney discards resulted in the Collaborative Innovation and Improvement Network (COIIN), a 3-year, HRSA-funded project addressing the need to increase the utilization of moderate-to-high KDPI kidneys while maintaining favorable patient and graft survival.5 The project uses a variation of the Institute for Healthcare Improvement’s Breakthrough Series Collaborative Improvement framework in which participant transplant programs engage in 90-day improvement cycles, testing effective practices distilled from high-utilization and exemplary practitioner organizations.
MATERIALS AND METHODS
The COIIN pilot project, spanning October 2015 to September 2018, includes the design, implementation, and evaluation of an altered collaborative improvement framework to meet the unique field of transplantation. Lead by a team of experienced performance improvement staff at United Network for Organ Sharing (UNOS), the project engaged 2 cohorts of participant teams, from 19 kidney transplant programs during October 2016 to September 2017, and an additional 39 participant programs from July 2017 to June 2018. Pilot groups were given a package of effective practices assembled by a 2016 Think Tank convention of practice model organizations shown to have success in identifying key drivers and processes contributing to higher acceptance rates of moderate-to-high KDPI kidneys while maintaining standards of favorable patient and graft survival (Figure 1).
;)
FIGURE 1: Modified collaborative improvement framework utilized in COIIN.
The practices were tested using The Model for Improvement through 3 90-day cycles focused on subprocesses of the kidney transplant process continuum:
- waitlist management,
- organ offer and acceptance,
- and posttransplant care coordination.6
To engage teams in collaboration, the project implemented a virtual classroom site to house participant team data, resources, virtual workspaces, and discussion boards. Outcome, process, and engagement data were monitored monthly, and the inclusion of qualitative surveys was used to gather feedback from participants. Additionally, SRTR-supplied CUSUM and outcomes data for each pilot program were shared across the collaborative.
RESULTS
The first pilot cohort of hospitals (cohort A) appreciated a collective increase of 99 kidney transplants from the 50% to 100% KDPI subgroup from January to September 2017 compared to the same time a year prior. Of the nineteen participating hospitals, fourteen (74%) appreciated a relative increase in moderate-to-high KDPI transplants. Utilization rates (percent of deceased donor transplants that were performed using donors with KDPI >50%) increased and cohort A demonstrated a 7.7 %increase in the average utilization of moderate-to-high kidneys (from 42.8% to 46.1%, P = 0.04) (Figure 2).
FIGURE 2: Utilization rate (50-100% KDPI) for all deceased donor kidney transplants performed by the first cohort of participants from January 2016 to February 2018, with national benchmark rates included for comparison. The active improvement period is displayed from January to September 2017 (data supplied by the UNOS as the contractor for the OPTN. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy of or interpretation by the OPTN or the US Government).
Aside from achieving an increase in mean utilization for moderate-to-high KDPI kidneys, participant teams collectively shared their learnings, challenges, and successes with one another on monthly conference calls. Faculty from practice model organizations imparted field tools and resources to supplement the improvement work of pilot teams. In a feedback survey administered to pilot teams after their active improvement participation, 95% of respondents indicated their program had improved at least 1 process within their organ offer and acceptance, waitlist management, and care coordination practices. Additionally, all respondents indicated interest in pursuing future collaborative improvement work with the OPTN/UNOS.
Throughout the pilot phase, discussion of challenges to improvement work was encouraged to collectively and creatively devise practical solutions participant teams could use. Some of these challenges included:
- Staffing changes impacting project sponsorship and/or meeting participation;
- Time commitments to review data, PDSAs (plan-do-study-act), and project work;
- Technological difficulties including data displays on the virtual learning site or updating manual processes within an electronic medical record.
Pilot teams shared solutions such as holding project meetings back-to-back with other critical meetings (such as Quality Assurance and Performance Improvement or Organ Offer Review meetings), forming new ways to communicate project work among teams, such as newsletters and prioritizing technological enhancements as part of ongoing PDSA cycles.
CONCLUSION
The second pilot phase of active improvement cycles will conclude in June 2018, and sustainability analyses will be conducted with continued data collection for 6 to 12 months after the end of the intervention periods of both cohorts.7 Collaborative Innovation and Improvement Network will be evaluated as just one of many potential approaches to targeting the increase utilization of moderate-to-high KDPI kidneys. Additional longitudinal studies will supplement the evaluation including structures and processes contributing to the preliminary results for the pilot phases of COIIN. These may include the collaborative framework, staffing, team composition, change package, improvement coaching, and use of data sharing to drive improvement. Based on our longitudinal quantitative and qualitative data analysis, we expect to accumulate further recommendations for collaborative improvement within transplantation.
ACKNOWLEDGMENTS
The authors would like to thank the Health Resources and Services Administration for sponsoring the project and the following organizations for their participation in the first pilot phase of COIIN: Brigham and Women’s Hospital, Thomas Jefferson University Hospital, Augusta University Health, Ochsner Foundation Medical Center, Methodist Dallas Medical Center, Scripps Green Hospital, University of Utah Medical Center, The Mayo Clinic, Virginia Mason Medical Center, Oregon Health and Science University Hospital, University of Washington Medical Center, University of Chicago Medical Center, Northwestern Memorial Hospital, Rush University Medical Center, University of Minnesota Medical Center, University of Colorado Hospital Health Science Center, New York Presbyterian Weill Cornell Medical Center, Ohio State University Medical Center, University of Virginia Health Sciences Center.
This work was conducted under the auspices of the United Network for Organ Sharing (UNOS), contractor for OPTN, under Contract 234-2005-370011C (US Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation).
REFERENCES
1. Tanriover B, Mohan S, Cohen DJ, et al. Kidneys at higher risk of discard: expanding the role of dual kidney transplantation.
Am J Transplant. 2014;14:404–415.
2. Stewart DE, Garcia VC, Rosendale JD, et al. Diagnosing the decades-long rise in the deceased donor kidney discard rate in the United States.
Transplantation. 2017;101:575–587.
3. Massie AB, Luo X, Chow EK, et al. Survival benefit of primary deceased donor transplantation with high-KDPI kidneys.
Am J Transplant. 2014;14:2310–2316.
4. Snyder JJ, Salkowski N, Wey A, et al. Effects of high-risk kidneys on scientific registry of transplant recipients program quality reports.
Am J Transplant. 2016;16:2646–2653.
5. Reese PP, Harhay MN, Abt PL, et al. New solutions to reduce discard of kidneys donated for transplantation.
J Am Soc Nephrol. 2016;27:973–980.
6. Langley GL, Moen R, Nolan KM, et al.
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass Publishers; 2009.
7. Wells S, Tamir O, Gray J, et al. Are quality improvement collaboratives effective? A systematic review.
BMJ Qual Saf. 2017;27:226–240.
http://qualitysafety.bmj.com/. Published October 21, 2017. Accessed November 20, 2017.
