Project Guidelines

Transplant is a treatment option that offers the opportunity for better clinical outcomes. This quality improvement activity focuses on increasing the number of patients on the United Network for Organ Sharing (UNOS) Waitlist.

Criteria: Include at least 30% of facilities in Network service area

Baseline: Period of six months (October 2016 - June 2017) Re-measure:  (January 2018 - September 2018)

Goals: Facilities selected for this project will demonstrate a 10% increase in the number of patient on the transplant waitlist

The Network staff will use the 7 Step process described by Sullivan, et al (2012) to monitor the patient progression through this process of getting on a transplant waitlist. These steps track the patients through their navigation from initial interest in transplant to final placement on the waitlist.

The 7 Steps are as follows:

  • Suitability for referral to transplant center
  • Interest in transplantation
  • Referral call to transplant center
  • First visit to transplant center
  • Transplant center work up
  • Successful transplant candidate
  • On waiting or evaluate living donor


ESRD National Coordinating Center (ESRD NCC)
     ESRD NCC Transplant LAN recordings
     National Patient Subject Matter Experts Transplant Affinity Group webpage

New York State Transplant Coalition webpage

Project Interventions

• Utilize Network-Developed Resource Toolkit
• Develop dedicated Treatment Options “Education Station” Tips PDF;  Poster PDF
• Submit Reporting Requirements (RCA/CAP, Monthly Collection Tool, Use Forecasting Tool)
• Participate in Network Site Visits
• Establish Peer Mentor Program
• Participate in Network’s Transplant Advisory Committee

QIA Resources

QIA Resource online order form

Transplant QIA 2018 Activity Checklist  PDF

Transplant Resource Toolkit webpage
Peer Mentorship Training Program Page

Transplant Resources

American Society of Transplantation Patient Resources webpage
Ascent To Transplant webpage
Ascent to Transplant Webinar: Kidney Allocation System and Impacts to Patient Care
Donate Life webpage
Transplant Living: Learning Center webpage

What is a referral?  The CMS definition of a Transplant Referral: “any first-time referral for a patient (i.e., the patient has not already been referred or been placed on a transplant waitlist), and for which either a dialysis facility or transplant center provides an indication that the patient has been referred. Patients who have had transplant failures are considered as restarting the referral process anew, and would be eligible for “first-time” referrals.”

ESRD NCC Transplant QIA LAN Calls

August 21, 2018 The Kidney Transplant WorkupAmy Schurke, RN, BSN, CCTCExplain how patient is referred
Define initial phone contact with patient
Define Transplant Work up and all that is involved
Discuss importance of care partner support
Discuss expectations of the recipient throughout the workup once listed
Discuss Barriers/Hurdles patients may have prior to starting the transplant process
June 19, 2018Transplant from the Clinic’s PerspectiveKay Kerby, LCSW• Learn importance of regularly monitoring patients and their transplant status.
• Identify barriers to transplant.
• Understand the importance of utilization and coordination with the Interdisciplinary Team (IDT) and community resources to facilitate a successful transplant process.

Step 1: Suitability for referral to
transplant center
Step 2: Interest in transplantation
Step 3: Referral call to transplant center
April 17, 2018Patients Helping Patients Navigate the Seven Steps to Wait ListingAnne Huml, MD Kate Greenway, BS
Sara Cox, MSW, LISW
Jennifer Truster, BSN
• Discuss how the mechanisms of transplant (7 steps toward transplant wait listing) were identified and the common barriers encountered at each step.
• Describe the role of a patient navigator and how this model can be utilized to create peer-to-peer patient engagement activities to assist patients in working through the process for transplant wait listing.
• List interventions to overcome barriers with a peer-to-peer approach or hemodialysis unit assistance.
All steps
February 20, 2018Creating a Successful Transplant Outreach ProgramChristina Psathas, MADescribe the transplant center’s approach to increase patient and staff engagement in the kidney transplant process
• Identify the key responsibilities of a transplant surgeon designee
• Discuss the evolution of the transplant surgeon designee program created and developed by Saint Barnabas Medical Center
Step 3: Referral call to transplant center
Step 4: First visit to transplant center
Step 6: Successful transplant candidate

Patient and Healthcare Team

For more information:

Jeanine Pilgrim
Quality Improvement Director
(516) 209-5365

Anna Bennett
Quality Improvement Coordinator
Emergency Manager
(516) 209-5474

John Cocchieri
Data Coordinator, Quality Improvement
(516) 209-5515


August (QIA Checklist)
July (Education Station Contest)