Anne Sanford, RN, QA Manager

I support the proposal to eliminate routine 3 year cycle surveys because: • UNOS and CMS are duplicative in many areas • UNOS addresses patient safety compliance whereas CMS looks more at overall institutional compliance of administrative regulations • The consequences of less than 100% administrative regulation compliance accuracy are out of line with the “danger” to patients of non-compliance with administrative regulations • CMS regulations are not clearly defined and are subject to interpretation by a given group of surveyors; CMS has not addressed this despite continual input from the transplant community • Corrective Action Plans are submitted but no feedback is received by the center about the individual corrective initiatives they propose (except at the mitigating factors level) • Neither UNOS nor CMS currently focuses on outcomes and targeted improvement initiatives • Elimination of the focus on “survey readiness” as it exists now would allow staff to focus on process improvement and clinical outcome improvement • Elimination of data collection by the tedious audit of individual patient charts to check for compliance with administrative regulations would allow us to partner with other CMS-regulated entities, such as ESRD Network 18, on efficiencies and cost saving efforts • Consolidation would result in efficiencies which translate into $$$ on the Medicare Cost Report. Our center employs 8 individuals in the Transplant Quality Department alone: 1 manager, 2 RNs, 5 data coordinators Rather, focus on accurate data submission, outcomes, and further, request and “grade” improvements in a standardized fashion that is ONLY required for observed less than expected outcomes reflected in the data submissions. Do not substitute a greater burden of data submission for the 3 year surveys