QI 1.3 Systematic The Plan is based on specific quality indicators that are linked to the goals. organization’s Consider observing these goals in the published organization goals, Quality Policy Statements, Improvement Projects, and the Quality Plan. The methodology for implementing the Plan is defined (Policy & Procedures, PDSA, Project Management) QI 1.4 Organization-wide - All OPO departments are explicitly referenced in the Quality Plan. - All OPO departments are involved in the development of the Quality Plan. QI 2 DATA COLLECTION AND ANALYSIS QI 2.1 Systematic Data Collection: - The surveyor shall have access to the standard data reports utilized by the OPO. The OPO collects data for both - The source of the data is documented. Examples of sources are AOPO, SRTR, improvement priorities and ongoing UNOS, and other internal sources. measurement. This data should focus on: The data describing operational volumes may address measurements related to Operational volumes recovered and/or transplanted organs by organ type, frequency of surgical Operational outcomes problems/errors encountered, conversion ratios pertaining to potential donors, etc. and/or other indicators that focus on the desired performance and/or problem prone Areas of risk or potential risk areas for that OPO. Consider improvement project reports, data reports, and the Quality Plan to observe organizational choices on the type of data to be collected and the scope of data collection. There is a documented method for prioritizing the data. QI 2.2 Data Time Frames The frequency and detail of the analysis should be demonstrated and explained using the following components at a minimum: A period of time for collection of Statistical methodology specific data is defined prior to review Internal comparison and analysis. External comparison Intensive assessment when there is undesirable variation. QI 2.3 Review - Baseline performance is determined for each quality indicator. The OPO makes internal comparisons - Statistical tools are used to review data. Some examples are run charts, histograms, of its performance of process and pareto charts, scatter plots, and control charts. outcomes over time. - Any example of a statistical method being utilized should be verified with documentation of The OPO compares performance data the type and the rationale for its use in each instance. methodology’s
QI 1.3 Systematic The Plan is based on specific quality indicators that are linked to the organization’s goals. Consider observing these goals in the published organization goals, Quality Policy Statements, Improvement Projects, and the Quality Plan. The methodology for implementing the Plan is defined (Policy & Procedures, PDSA, Project Management) QI 1.4 Organization-wide - All OPO departments are explicitly referenced in the Quality Plan. - All OPO departments are involved in the development of the Quality Plan. QI 2 DATA COLLECTION AND ANALYSIS QI 2.1 Systematic Data Collection: The OPO collects data for both improvement priorities and ongoing measurement. This data should focus on: Operational volumes Operational outcomes Areas of risk or potential risk - The surveyor shall have access to the standard data reports utilized by the OPO. - The source of the data is documented. Examples of sources are AOPO, SRTR, UNOS, and other internal sources. The data describing operational volumes may address measurements related to recovered and/or transplanted organs by organ type, frequency of surgical problems/errors encountered, conversion ratios pertaining to potential donors, etc. and/or other indicators that focus on the desired performance and/or problem prone areas for that OPO. Consider improvement project reports, data reports, and the Quality Plan to observe organizational choices on the type of data to be collected and the scope of data collection. There is a documented method for prioritizing the data. QI 2.2 Data Time Frames A period of time for collection of specific data is defined prior to review and analysis. The frequency and detail of the analysis should be demonstrated and explained using the following components at a minimum: Statistical methodology Internal comparison External comparison Intensive assessment when there is undesirable variation. QI 2.3 Review The OPO makes internal comparisons of its performance of process and outcomes over time. The OPO compares performance data - Baseline performance is determined for each quality indicator. - Statistical tools are used to review data. Some examples are run charts, histograms, pareto charts, scatter plots, and control charts. - Any example of a statistical method being utilized should be verified with documentation of the methodology’s type and the rationale for its use in each instance.