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Quality Update - Transplant turnaround

Winter 2011

Transplant turnaround

Date: January 20, 2011

Better data tracking empowers a kidney program to improve patient access and increase revenue.

When administrators for Johns Hopkins’ kidney transplant program looked for reasons why they were performing fewer procedures—despite getting more referrals than ever—it was no surprise that patient access was one of the areas that they would scrutinize. They had heard scattered grumblings from patients and referring physicians that candidates had trouble getting appointments for evaluations.

However, this anecdotal evidence didn’t explain why referrals were getting bogged down nor how to fix the problem. For those answers, they needed to get back to one of the basics of quality improvement—measurement.

“We had been looking at the number of transplants performed and the number of patients put on our waiting list” for new kidneys, says Diane Lepley, a quality improvement team leader at The Johns Hopkins Hospital. “What we didn’t understand were the steps in the referral process, if all the steps were needed to get patients to those end points, how long each of those steps took, and whether that time was reasonable.”

Seeking this information, a group from the transplant program, Quality Improvement and the Center for Innovation in Quality Patient Care turned to Lean Sigma. A proven tool for streamlining systems, Lean Sigma emphasizes the use of process mapping and measurement to shine a light on where systems are breaking down.

Together with Julie Cady-Reh, a Lean Sigma coach at the Center for Innovation, Lepley met with staff members to learn about their roles in handling referrals, such as determining insurance coverage and collecting medical records from patients. Staff wrote their tasks on sticky notes and arranged them on a wall according to the sequence that they’re performed, helping Cady-Reh and Lepley to construct a map for how referrals were handled.

Next, Lepley and Cady-Reh scoured a transplant center database for three months of referrals. They used the dates stamped on entries in the database to calculate how many days each step in the process took to complete.

The legwork took two weeks, but it was essential. The data led them to focus on the time between the referral and the evaluation of the patient’s suitability for transplant, a process that took more than three months. The analysis also told them that, of 100 patients who called the center over three months, just 29 made it to the point of having an evaluation scheduled. 

Transplant center leaders point out that some of the barriers to appointments were understandable. For example, not all patients referred to the center are appropriate, due to such issues as active drug use. Also, evaluation slots in the kidney program are limited by the number of surgeons to handle the cases and their busy schedules. Pre-screening patients can help insure that those slots are used wisely.

 “We need to work efficiently so that patients don’t decide to go elsewhere,” says Bryan Barshick, an assistant director of nursing with the transplant center. “But we also need to work effectively so we’re not wasting the medical team’s time.”

Still, the examiners found waste. For example, one step required on-call coordinators—nurses whose main job is to transport kidneys—to use their “down time” to telephone referred patients and collect their medical histories. The analysis found that patient files got held up at that step for 22 days on average, in part due to difficulty coordinating times to speak with patients. The value of these screenings was also questionable, because they often duplicated records collected at other steps.

When the transplant center revamped its referral-to-evaluation process, that telephonic medical history collection was eliminated. Other steps were also removed, leading the number of handoffs of patient files to drop from 10 to six.  

Among other changes, the program added two weekly evaluation slots when another transplant surgeon joined the center.

The overhaul resulted in a nearly 50 percent decrease in referral-to-evaluation time by the end of 2009. The improved throughput was among several changes that the program credits for boosting its evaluations (39 percent), patients placed on the wait list (22 percent) and transplants (44 percent) that year. The increase in kidney transplants had a multimillion-dollar impact on the program’s bottom line.

Perhaps as important is that the kidney program has automated measurement. Upgrades to the referral database allow users, including kidney transplant program nurse manager Susan Humphreys, to easily track how the system is performing at different steps, and to continue to improve.

“When you’re busy with a lot of referrals, unless you can measure what you’re doing wrong and see how to make it better, you feel hopeless,” Humphreys says.

The Center for Innovation’s next Lean Sigma course will be held March 21-25. Register: Two-day courses on applying Lean methodology to health care will be held May 3-4 and July 26-27. Register:


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