OPTN Evaluation Plan - Organ Procurement and Transplantation ...

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OPTN Member Evaluation PlanUpdated January 1, 2015Policy 15.4.B: Living Donor Recovery Hospital and Host OPO RequirementsEffective Date: 2/1/2014At OPOs, site surveyors will:Review a sample of deceased donor records for the following documentation:⦁ Reporting of any post-recovery cultures relevant to potential transmission of disease or medical conditions toall recipient transplant programsOPOs will provide:The requested sample of deceased donor medical recordsPolicy 16.1: Organs Not Requiring TransportEffective Date: 2/1/2014At Living Donor recovery hospitals, site surveyors will:Review a sample of living donor medical records, and any material incorporated into the medical record byreference, for documentation that:⦁ "Time outs" were performed⦁ Before leaving the donor operating room⦁ After arrival in the potential recipient's operating room⦁ According to the hospital's internal policies, procedures, and/or protocolsReview the living donor recovery hospital’s internal policies, procedures and/or protocols to verify that the hospitalhas developed and implemented written protocols that address:⦁ "Time outs"⦁ That they include a process for verifying:⦁ A unique identifier for the donor⦁ A unique identifier for the recipient⦁ That they are performed two times:⦁ In the donor operating room⦁ In the potential recipient's operating room, before anastomosisRecovery hospitals will provide:The requested sample of living donor recordsThe recovery hospital's internal policies, procedures and protocols for the care of living donors38
OPTN Member Evaluation PlanUpdated January 1, 2015Policy 16.6: Verification of Information before ShippingEffective Date: 2/1/2014At OPOs, site surveyors will:Review a sample of deceased donor records for the following documentation:⦁ Someone at the OPO, other than the individual who initially performed the labeling and documentation, hasverified the accuracy of each labelOPOs will provide:The requested sample of deceased donor medical recordsPolicy 16.7.A: Vessel Recovery and Transplant UseEffective Date: 2/1/2014At transplant hospitals, site surveyors will:Interview staff members that have been designated to oversee the storage and use of vessels, to verify knowledge that:⦁ vessels should only be used in implantation or modifications of organ transplants⦁ any vessels shared with another transplant hospital must be reported to the OPTN⦁ vessel disposition (including use and disposal) must be reported to the OPTNTransplant hospitals will provide:Access to relevant staff who can answer interview questionsAdditional Guidance:The receiving transplant hospital is not required to report vessels as shared when it receives vessels directly from therecovering OPO.All vessels shared between hospitals must be reported, even if they are not used.39
Page 1 and 2: OPTN Member Evaluation PlanUpdated
Page 3 and 4: Policy 8.5.A: Candidate Classificat
Page 9 and 10: Policy 2.8: Required Deceased Donor
Page 11 and 12: Policy 2.11.B: Required Information
Page 17 and 18: Policy 6.1.A: Adult Heart Status 1A
Page 21 and 22: Policy 8.5.E: Allocation of Kidneys
Page 25 and 26: Policy 9.3.H: MELD/PELD Score Excep
Page 27 and 28: Policy 13.2: Potential KPD Donor Re
Page 35 and 36: Policy 14.4.B: Living Kidney Donor
Page 37 and 38: ⦁ Personal history of:⦁ Hyperte
Page 41: OPTN Member Evaluation PlanUpdated
Page 47 and 48: Policy 18.5.A: Reporting Requiremen
Page 49 and 50: Bylaws Appendix B.1: OPO Compliance
Page 51 and 52: Bylaws Appendix B.4: OPO PersonnelO
Page 55 and 56: Bylaws Appendix D.5: Transplant Pro
Page 57 and 58: Transplant hospitals must:Address e
Page 61 and 62: Bylaws Appendix D.10.A: Transplant
Page 63 and 64: Bylaws Appendix F.6.E: Conditional
Page 67 and 68: Bylaws Appendix K.4.A: Notice to th

OPTN Evaluation Plan - Organ Procurement and Transplantation ...

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